Vision Insurance Under the vision plan, you may purchase your eyeglasses and contacts at the eye care provider of your choice. When you use an Avesis network provider, you receive the highest level of plan bene昀椀ts and have the lowest out-of-pocket costs. For routine eye exams, you can see any Optometry provider; in or out-of-network. However, for non- routine eye care, you’ll need to visit an in-network provider. Vision Examination IN-NETWORK OUT-OF-NETWORK Includes refraction Covered in full after $10 copay Up to $35 Retinal Imaging Up to $45 member out-of-pocket N/A (OOP) maximum Materials $10 copay (Materials copay applies to frame or spectacle lenses, if applicable.) Frame Allowance Members receive a $65 wholesale Up to 20% discount above allowance up to $175 retail value† Up to $55 frame allowance.* Standard Spectacle Lenses Single Vision Up to $25 Bifocal Up to $40 Covered in full after $10 copay Trifocal Up to $50 Lenticular Up to $80 Preferred Pricing Options Level 6 Option Package Polycarbonate (Single $40/$44 N/A Vision/Multi-Focal) (Covered in full up to age 19) (Up to $10 for ages up to 19) Standard Scratch-Resistant $17 Coating Ultraviolet Screening $15 Solid or Gradient Tint $17 N/A Standard Anti-Re昀氀ective $45 Coating † Value may be less depending on the providers retail pricing. * Discounts are not insured bene昀椀ts. ‡ Enhanced bene昀椀t for certain conditons. ¥ Save up to 25% on average LASIK prices when you use Qualsight (visit qualsight.com/-avesis for more information). | 17 |