| 17 | Vision Insurance 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 (OOP) maximum N/A Materials $10 copay (Materials copay applies to frame or spectacle lenses, if applicable.) Frame Allowance Up to 20% discount above frame allowance.* Members receive a $65 wholesale allowance up to $175 retail value† Up to $55 Standard Spectacle Lenses Single Vision Covered in full after $10 copay Up to $25 Bifocal Up to $40 Trifocal Up to $50 Lenticular Up to $80 Preferred Pricing Options Level 6 Option Package Polycarbonate (Single Vision/Multi-Focal) $40/$44 (Covered in full up to age 19) N/A (Up to $10 for ages up to 19) Standard Scratch-Resistant Coating $17 N/A Ultraviolet Screening $15 Solid or Gradient Tint $17 Standard Anti-Reflective Coating $45 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 benefits 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. † Value may be less depending on the providers retail pricing. * Discounts are not insured benefits. ‡ Enhanced benefit for certain conditons. ¥ Save up to 25% on average LASIK prices when you use Qualsight (visit qualsight.com/-avesis for more information).