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obtained from a Participating Vendor. We will cover both of the following if, in the judgment of a Participating Provider, you must wear eyeglass lenses and contact lenses at the same time to provide a significant improvement in vision not obtainable with regular eyeglass lenses or contact lenses alone:  One conventional contact lens, or a 6-month supply of disposable contact lenses, determined by your Participating Provider for each eye on which you had cataract surgery, and fitting and follow-up care for the lens.  One pair of regular eyeglass lenses determined by your Participating Provider and a frame from a specified selection of frames. Vision Services for Adults Exclusions  Low vision aids.  Non-prescription products (other than eyeglass frames), such as eyeglass holders, eyeglass cases, repair kits, contact lens cases, contact lens cleaning and wetting solution, and lens protection plans.  Non-prescription sunglasses.  Optometric vision therapy and orthoptic (eye exercises).  Plano contact lenses or glasses (non-prescription).  Professional services for evaluation, fitting and follow-up care for contact lenses, except that this exclusion does not apply to contact lenses we cover under the “Medically Necessary Contact Lenses” or “Eyeglasses and Contact Lenses after Cataract Surgery” in this EOC.  Replacement of lost, broken, or damaged lenses or frames. 41. Vision Services for Children We cover vision Services for children at Participating Facility optical centers, when prescribed by a Participating Provider or a Non-Participating Provider and obtained from a Participating Vendor, until the end of the month in which the Member turns 19 years of age. The “Benefit Summary” describes your benefits and lists any Cost Share amounts, as well as any visit and/or additional limitations, under “Vision Services for Children.” After you reach the visit and/or device limitation, we will not cover any more Services for the remainder of the Year, or other identified benefit period. Examinations We cover routine vision screenings and a comprehensive eye examination with refraction, including dilation when determined to be Medically Necessary. Eyeglasses and Contact Lenses We cover one pair of eyeglass lenses (single vision, bifocal, lenticular, or trifocal, including polycarbonate lenses and scratch-resistant coating) determined by your Participating Provider and a frame, or contact lenses in lieu of eyeglasses. Prescription eyeglass lenses and frames, or contact lenses, including expenses associated with their fitting, is provided once per Year when obtained at a Participating Facility optical center. Eyeglasses and Contact Lenses after Cataract Surgery If you have cataract surgery and since that surgery we have never covered eyeglasses or contact lenses under any benefit for eyeglasses and contact lenses after cataract surgery (including any eyeglasses or contact lenses we covered under any other coverage), we cover your choice of one of the following, without charge, if obtained from a Participating Vendor. We will cover both of the following if, in the judgment of a Participating Provider, you must wear eyeglass lenses and contact lenses at the same time to provide a significant improvement in vision not obtainable with regular eyeglass lenses or contact lenses alone: EWCLGHDHP1983ACT0124 72 WAPEBB-CD-ACT

Kaiser Permanente NW CDHP EOC (2024) - Page 79 Kaiser Permanente NW CDHP EOC (2024) Page 78 Page 80