Group Vision Insurance Plan Summary

B.C. Clark Standard Insurance Company Group Vision Insurance Help protect your eye health with coverage for exams, glasses and contacts. This summary of benefits and coverage shows how you and The Standard would share the cost for covered vision care services. NOTE: This is only a summary; for detailed information on coverage, please consult your certificate of coverage. Plan 1: Balanced Care Vision I Plan Summary Effective Date: 10/1/2027 VSP Choice Network + Affiliates Out of Network Deductibles $10 Exam $10 Exam $10 Eye Glass Lenses or Frames* $10 Eye Glass Lenses or Frames Annual Eye Exam Covered in full Up to $45 Lenses (per pair) Single Vision Covered in full Up to $30 Bifocal Covered in full Up to $50 Trifocal Covered in full Up to $65 Lenticular Covered in full Up to $100 Progressive See lens options NA Contacts Fit & Follow Up Exams Covered in full Not covered Elective Up to $130 Up to $105 Medically Necessary Covered in full Up to $210 Frame Allowance $130** Up to $70 Frequencies (months) Exam/Lens/Frame 12/12/24 12/12/24 Based on calendar year Based on calendar year *Deductible applies to a complete pair of glasses or to frames, whichever is selected. **The Costco and Walmart allowance will be the wholesale equivalent. Lens Options (participant cost)* VSP Choice Network + Affiliates Out of Network (Other than Costco) Progressive Lenses Standard Covered in full Up to Lined Bifocal allowance. Premium Covered in full Up to Lined Bifocal allowance. Std. Polycarbonate Covered in full for dependent children $33 adults Not covered Solid Plastic Dye $15 (except Pink I & II) Not covered Plastic Gradient Dye $17 Not covered Photochromatic Lenses (Glass & Plastic) Covered in full Not covered Scratch Resistant Coating Covered in full Not covered Anti - Reflective Coating Covered in full Not covered Ultraviolet Coating Covered in full Not covered *Lens Option participant costs vary by prescription, option chosen and retail locations.