SELECTED BENEFITS, COPAYMENTS AND ALLOWANCES Clause Samples

SELECTED BENEFITS, COPAYMENTS AND ALLOWANCES. For a Covered Service received by an Enrollee, Surency will provide the Benefits subject to the amount listed for each benefit which is indicated in the “Summary of Vision Plan Benefits” section, or the amount which is otherwise payable in accordance with the other provisions of this Agreement. Vision Examination with Dilation as Necessary Retinal Imaging $10 Up to $39 $35 N/A Once every 12 months Contact Lens Fit and Follow-Up: (Contact lens fit and two (2) follow-up visits are available once a comprehensive eye exam has been completed.) Standard-spherical clear contact lenses in conventional wear and planned replacement. (Examples include but not limited to disposable, frequent replacement, etc.) $0 $40 Once every 12 months Premium-all lens designs, materials and specialty fittings other than Standard Contact Lenses (Examples include toric, multifocal, etc.) Access Network 10% off retail, then apply $55 allowance $40 Once every 12 months Frames: Any available frame at provider location. $130 Allowance $65 Once every 12 months Single Vision $25 Copay $25 Bifocal $25 Copay $40 Once every 12 months Trifocal $25 Copay $55 Lens Options: Standard Polycarbonate Adults: $40 Dependents under 19: $0 $25 $25 Once every 12 months UV Coating Tint (Solid and Gradient) Standard Scratch-Resistance Standard Anti-Reflective Coating Standard Progressive (Add-on to Bifocal) Premium Progressive Lenticular $15 $15 $15 $45 $65 $65 + 80% off Retail price less $120 $25 Copay Not covered Not covered Not covered Not covered $40 $40 $55 Once every 12 months Once every 12 months Other Add-Ons and Services 20% off Retail Price Not covered Contact Lenses: (Contact lens allowance includes materials only) (Allowance not available if eyeglass lenses are elected) Conventional $130 allowance 15% off balance over $100 Once every 12 months Disposable $130 allowance $100 Medically Necessary $0 $200