Common use of Limitations and Exclusions Clause in Contracts

Limitations and Exclusions. The limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and

Limitations and Exclusions. The limitations This warranty applies only to products manufactured for GROHE after September 1, 2016 and exclusions in this section purchased by the original consumer-purchaser in, and installed in, either the United States, Canada, or Mexico. This warranty applies only if the product was properly installed, mounted, operated, cared for, and cleaned, irrespective of whether installation and/or mounting is performed by a qualified specialist fitter or the original consumer-purchaser. This warranty shall not apply to all pediatric vision benefitsany products or spare parts: not properly installed, cared for, maintained, or repaired in accordance with GROHE’s instructions, valid water regulations, and/or best plumbing practices; defective out of the box; not installed or removed; damaged due to incorrect operation, handling, transportation, installation, breakage of fragile parts, or missing or incorrect maintenance; repaired or maintained by or with spare parts other than original GROHE spare parts; scratched; used as displays; that are second hand; with affected consumables (such as batteries, filters, filter cartridges, aerators or batteries) or material subject to wear and tear (such as seals); damaged due to environmental influences or circumstances (such as chemicals and cleaning agents, pressure in the line, or voltage), lime scale or disruptions to ice and/or lime; damaged due to willfulness or negligence by the end customer or a third- party; or purchased on auction sites (either consumer-to-consumer or second hand). Although HMO With the exception of missing component parts, notice of which must be given within thirty (30) days of purchase, notification must be given within a reasonable time after discovery of the defect, but no later than expiration of the warranty period. This warranty is non-transferable. THIS WARRANTY IS IN LIEU OF ALL OTHER WARRANTIES, INCLUDING ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. XXXXX WILL NOT BE LIABLE FOR ANY LOSS, DAMAGE, EXPENSE OR INCIDENTAL OR CONSEQUENTIAL DAMAGES OF ANY KIND, WHETHER BASED ON WARRANTY, CONTRACT OR NEGLIGENCE AND ARISING IN CONNECTION WITH THE SALE, USE OR REPAIR OF ANY PRODUCTS OR PARTS. SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF CONSEQUENTIAL DAMAGE OR LIMITATIONS ON HOW LONG AN IMPLIED WARRANTY LASTS, SO THE ABOVE LIMITATIONS OR EXCLUSIONS MAY NOT APPLY. This warranty gives the original consumer-purchaser specific legal rights which may list vary from country to country, state to state, or province to province. In some countries, states, or provinces, the exclusion or limitation of incidental or consequential damages is not allowed, so those exclusions may not apply. UNLESS OTHERWISE CONTRARY TO THE LAW GOVERNING THE PURCHASE, GROHE’S LIABILITY WILL NOT EXCEED THE CONTRACT PRICE FOR THE PRODUCT CLAIMED TO BE DEFECTIVE. SUBMITTING A WARRANTY CLAIM: To submit a specific service as a benefitwarranty claim, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care original purchaser-owner should submit the information listed below to GROHE Customer Service at us- xxxxxxxxxxxxxxx@xxxxx.xxx or treatment of a covered conditionthrough our website at xxxxx://xxx.xxxxx.xxx/us/5685/services- for-you/warranties/. Telephone inquiries may be directed to (000) 000-0000. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered serviceProduct/model number;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) OutProof-of-Network Allowance purchase (maximum reimbursement amount payable by HMOcopy of original sales receipt, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Framespurchase order, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu invoice showing the date of spectacle lenses Elective Conventional Disposable You receive 15% off balance purchase);  Documentation confirming date of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopesinstallation; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and

Limitations and Exclusions. The limitations and exclusions in this section This Warranty does not apply to all pediatric vision benefits. Although HMO may list a specific service as a benefitany defect, HMO will not cover it unless we determine it failure, damage, or undue wear in or to the Surface caused by or connected with: (a) improper or insufficient design or engineering, or improper or insufficient project drawings, plans or specifications; (b) an inadequate or defective pre-existing base or surface; (c) the inherent characteristics of the earth or surface upon which the Surface is necessary for the preventioninstalled; (d) misuse, diagnosisabuse, care bubbles, or treatment deliberate acts of a covered condition. We do not cover the following:  Any vision servicevandalism; (e) accident, treatment negligence, or materials not specifically listed as a covered serviceacts of God;  Services and materials that are experimental (f) static or investigationaldynamic loads exceeding Midwest Track Builders recommendations;  Services and materials that are rendered prior to Your effective date(g) use of improper cleaning methods;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your or (h) Owner's failure to comply care for and maintain the Surface in accordance with professionally prescribed treatment;  Telephone consultations;  Any charges for failure Midwest Track Builders written instructions. Midwest Track Builders does not warrant or guarantee the accuracy or sufficiency of any drawings, plans or specifications not prepared by Midwest Track Builders and which are used in connection with installing the Surface. This Warranty shall not apply to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, chartsthe Surface, or any costs associated part thereof, which has been repaired or altered without Midwest Track Builders prior written consent. No allowance or credit will be granted for any repairs or alterations to the Surface made by Owner except as authorized by this Warranty. THIS WARRANTY IS EXPRESSLY IN LIEU OF ALL OTHER WARRANTIES, EXPRESS, IMPLIED OR ARISING BY OPERATION OF LAW, INCLUDING (BUT NOT LIMITED TO) ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE AND OF ALL OTHER OBLIGATIONS OR LIABILITIES ON MIDWEST TRACK BUILDERS PART. MIDWEST TRACK BUILDERS SHALL NOT BE LIABLE FOR ANY INCIDENTAL, CONSEQUENTIAL, SPECIAL OR INDIRECT DAMAGES UNDER THIS WARRANTY, INCLUDING BUT NOT LIMITED TO ANY ACTIONS ALLEGING DAMAGES UNDER TORT, CONTRACT OR STRICT LIABILITY. MIDWEST TRACK BUILDERS SOLE OBLIGATION UNDER THIS WARRANTY IS TO REPAIR AT ITS SOLE DISCRETION ANY PORTION OF THE SURFACE WHICH MAY BE DETERMINED TO BE DEFECTIVE. MIDWESTS LIABILITY FOR ANY SUCH REPAIR SHALL IN NO EVENT EXCEED THE AMOUNT OF THE PURCHASE PRICE ATTRIBUTABLE TO THE DEFECTIVE PORTION OF THE SURFACE WHICH IS REPAIRED. Midwest Track Builders neither assumes nor authorizes any person to assume for it any other liability in connection with forwarding/mailing copies of Your records the sale, installation or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member use of the HMO vision care plan so that Your eligibility can be verifiedSurface. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may This Warranty shall not be combined with construed to be an obligation of any discount, promotional offering, performance or other group benefit plansbond furnished by any party in connection with Midwest Track Builders contract for the Surface and shall not be enforceable against any such party. Allowances are oneAll pre-time use benefits; no remaining balances are carried over to be used laterexisting base or surface upon which the Surface has been installed is specifically excluded from any coverage by this Warranty. Schedule Midwest Track Builders previous acceptance of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost any such pre-existing base or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services surface for contact lens evaluations. Any applicable fees are the responsibility installation of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of Surface shall not be deemed to constitute a warranty or other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS andguarantee thereof.

Limitations and Exclusions. The limitations Unless otherwise agreed to in writing by NetScout, Product is eligible for Maintenance support services provided such Product remains in the location to which such Product was originally shipped, and exclusions with respect to Hardware, provided such Hardware is within the applicable Hardware coverage period. If customer moves the Product from one location to another (“Product Relocation”), customer (a) does so at customer’s own risk, loss and expense, (b) is responsible for obtaining all necessary licenses to export, re-export or import the Product, and (c) will indemnify, defend and hold NetScout harmless from and against any and all claims, demands, suits, actions, damages, liabilities, fines, penalties, losses, and expenses including without limitation attorneys’ fees and disbursements and court costs (collectively, “Claims”) arising from Product Relocation. Failure to notify NetScout of Product Relocation may result in an inability for NetScout to perform its warranty obligations or Maintenance in accordance with this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefitMaintenance Description, HMO and NetScout will not cover it unless we determine it is necessary be liable for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials any Claims resulting from Your failure Product Relocation. NetScout is not obligated to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, chartsprovide Updates containing additional features and enhancements other than defect corrections, or any costs associated with forwarding/mailing copies of Your records to provide MasterCare or charts;  State or territorial taxes Gold Support on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription Software beyond two (Plano2) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the releases back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder current version. NetScout is payable not liable for delays caused by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, third parties. Geographical restrictions or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider the Maintenance support services described herein and such services may not be available in all areas. Onsite repair may be provided by a third party and subject to parts availability. Same day service is not available in all areas. If customer has a party other than NetScout make repairs to the Products, such acts will void any warranty related to the Products. NetScout is not obligated to provide Maintenance support services with respect to claims resulting from the fault or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details negligence of customer or a third party; improper or unauthorized use of the warranty that is available Products; repair of Products by a party other than NetScout or its authorized contractor; a force majeure event and any causes external to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser Product such as power failure or electric power surge; modification to factory default configurations; or use of the maximum allowance noted Products in combination with equipment or software not supplied by NetScout or recommended in the retail costProduct Documentation. Retail prices vary by locationFunctional upgrades such as faster processors, increased memory / flash, etc. RIDERS andare not covered under MasterCare or Gold Support and are separately chargeable at the then-current list price.

Limitations and Exclusions. The limitations Notwithstanding that the Product is within the Warranty Period, this warranty shall be invalidated and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover rendered void upon the following:  Any vision serviceThe Product serial number, treatment or materials warranty seal has been removed, erased, defaced, altered, tampered or is illegible; or The Product shows evidence of commercial use; impact, shock; accident; fire, flood, earthquake, lightning or other acts of nature; sand, liquid or food damage; exposure to extreme thermal or environmental conditions beyond product specifications or a rapid change in such conditions; electrostatic discharge; battery or chemical corrosion; abuse, mishandling, improper installation, operation or maintenance, use of wrong electrical supply or voltage; damage during shipment to / from our authorised service centre; damage caused by installation of any software, programs or applications, or use of any accessories, or consumable items; improper alteration, modification, adjustment, tampering; replacement of parts with parts not specifically listed as a covered serviceprovided or approved by AquaNova;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after dismantling, opening, service or repair performed other than by our authorised service centre. This warranty does not cover: Missing accessories or external parts of the termination Product, unless such claim is made within 3 days from the date of Your coverage unless otherwise indicatedoriginal retail purchase;  Services Cosmetic damage to outer surface/finishing and materials not meeting accepted standards external parts of optometric practicethe Product, including without limitation cracks, dents or scratches on the exterior casing, screen, buttons and other attachments;  Services Deterioration of the Product due to normal wear and materials resulting from Your failure to comply with professionally prescribed treatmenttear, including without limitation rust or stains;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature includingGeneral maintenance, but not limited toroutine servicing and cleaning, charges for personalization or characterization updating/upgrading of prosthetic appliances;  Office infection control charges;  Charges for copies of Your recordssoftware, chartsproduct demonstration, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other service other than those described repair; Any other circumstance such that repair would be contradictory or not in this benefit;  Replacement compliance with good business practice. To the fullest extent permitted by law, the warranty expressly provided herein is the sole and exclusive warranty provided in connection with the Product and no other warranties, representations, endorsements or conditions of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Providerkind, whether oral, written, express, implied or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with statutory, including without limitation any discountimplied warranties of quality, promotional offering, merchantability or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers fitness for a particular covered servicepurpose, and warranties against hidden or latent defects, are provided. ** HMO pays In so far as any warranties cannot be excluded, such warranties shall be limited to the lesser terms of this warranty and for the Warranty Period expressed herein. To the fullest extent permitted by law, AquaNova shall not be in any way liable for any consequential, incidental, indirect, special or similar damages whatsoever arising from or in connection with the use, inability to use or performance of the maximum allowance noted Product, including without limitation loss of revenue, loss of profits, loss of opportunity, loss of business, loss of goodwill, loss of reputation, failure to realise savings or other benefits, loss of use of the retail Product or any associated equipment, loss of or damage to other property due to the malfunction of the Product, costs of substitute equipment, loss due to downtime cost, whether due to breach of warranty, strict liability, product liability, the negligence of AquaNova, or otherwise, even if AquaNova is aware of the possibility of such damages. Retail prices vary In no event shall any recovery against AquaNova exceed the actual price paid for the purchase of the Product. Without limiting the generality of the foregoing, you assume all risk and liability for loss, damage or injury to you and your property and to any third parties and their property arising out of the use, misuse or inability to use the Product not caused directly by locationthe negligence of AquaNova. RIDERS andYou agree and acknowledge that XxxxXxxx’s exclusions and limitations of liability are reasonable in the circumstances.

Limitations and Exclusions. The THIS WARRANTY SETS FORTH IAMI’S MAXIMUM LIABILITY FOR ITS PRODUCTS. IAMI MAKES NO OTHER WARRANTY, EXPRESSED OR IMPLIED, INCLUDING IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE WITH RESPECT TO ITS PRODUCTS EXCEPT AS IT IS SET FORTH. NO DISTRIBUTOR, DEALER OR REPRESENTATIVE HAS THE AUTHORITY TO CHANGE OR MODIFY THIS LIMITED WARRANTY. IN NO INSTANCE SHALL IAMI BE RESPONSIBLE FOR INDIRECT, CONSEQUENTIAL OR INCIDENTAL DAMAGES. This warranty gives you specific legal rights and you may also have other rights which vary from state to state. Some states do not allow the exclusion or limitation of implied warranties or of incidental or consequential damages, so the limitations and or exclusions in this section may not apply to all pediatric vision benefitsyou. Although HMO IN SUCH CASE, THE DURATION OF ANY IMPLIED WARRANTY SHALL BE THE SAME AS THAT OF THE EXPRESSED WARRANTY STATED HEREIN. NOTE: IAMI reserves the right to make product improvement changes in specifications, materials, and construction details. IAMI’s premier hardwoods vary in color and grain, which can affect the actual finish color. Variances in photography and printing may list also cause finish colors shown in catalogues and as displayed on a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment computer to vary from actual finishes. Final lines and details of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials delivered product may vary slightly from that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verifiedconcept CAD drawings supplied during quoting and specification. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or This variation is not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used laterconsidered a defect. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the MemberHANDLING, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS andJOB FINISHING AND INSTALLATION INSTRUCTIONS

Limitations and Exclusions. The limitations This warranty applies only to products manufactured for GROHE after September 1, 2016 and exclusions in this section purchased by the original consumer-purchaser in, and installed in, either the United States, Canada, or Mexico. This warranty applies only if the product was properly installed, mounted, operated, cared for, and cleaned, irrespective of whether installation and/or mounting is performed by a qualified specialist fitter or the original consumer-purchaser. This warranty shall not apply to all pediatric vision benefits. Although HMO may list a specific service any products or spare parts: not properly installed, cared for, maintained, or repaired in accordance with GROHE’s instructions, valid water regulations, and/or best plumbing practices; defective out of the box; not installed or removed; damaged due to incorrect operation, handling, transportation, installation, breakage of fragile parts, or missing or incorrect maintenance; repaired or maintained by or with spare parts other than original GROHE spare parts; scratched; used as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered servicedisplays;  Services and materials that are experimental second hand; with affected consumables (such as batteries, filters, filter cartridges, aerators or investigationalbatteries) or material subject to wear and tear (such as seals);  Services damaged due to environmental influences or circumstances (such as chemicals and materials that are rendered prior cleaning agents, pressure in the line, or voltage), lime scale or disruptions to Your effective dateice and/or lime;  Services and materials incurred damaged due to willfulness or negligence by the end customer or a third- party; or purchased on auction sites (either consumer-to-consumer or second hand). With the exception of missing component parts, notice of which must be given within thirty (30) days of purchase, notification must be given within a reasonable time after discovery of the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature includingdefect, but not limited tono later than expiration of the warranty period. This warranty is non-transferable. THIS WARRANTY IS IN LIEU OF ALL OTHER WARRANTIES, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your recordsINCLUDING ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. XXXXX WILL NOT BE LIABLE FOR ANY LOSS, chartsDAMAGE, EXPENSE OR INCIDENTAL OR CONSEQUENTIAL DAMAGES OF ANY KIND, WHETHER BASED ON WARRANTY, CONTRACT OR NEGLIGENCE AND ARISING IN CONNECTION WITH THE SALE, USE OR REPAIR OF ANY PRODUCTS OR PARTS. SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF CONSEQUENTIAL DAMAGE OR LIMITATIONS ON HOW LONG AN IMPLIED WARRANTY LASTS, SO THE ABOVE LIMITATIONS OR EXCLUSIONS MAY NOT APPLY. This warranty gives the original consumer-purchaser specific legal rights which may vary from country to country, state to state, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household membersprovince to province. In some countries, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglassesstates, or contact lensesprovinces, please call ahead for an appointmentthe exclusion or limitation of incidental or consequential damages is not allowed, so those exclusions may not apply. When You arriveUNLESS OTHERWISE CONTRARY TO THE LAW GOVERNING THE PURCHASE, show GROHE’S LIABILITY WILL NOT EXCEED THE CONTRACT PRICE FOR THE PRODUCT CLAIMED TO BE DEFECTIVE. SUBMITTING A WARRANTY CLAIM: To submit a warranty claim, the receptionist Your identification card. If You forget original purchaser-owner should submit the information listed below to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the GROHE Customer Service at us- xxxxxxxxxxxxxxx@xxxxx.xxx or through our website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the tollxxxxx://xxx.xxxxx.xxx/us/5685/services- for-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglassesyou/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there warranties/. Telephone inquiries may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examinationdirected to (000) 000-0000. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits• Product/model number; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out• Proof-of-Network Allowance purchase (maximum reimbursement amount payable by HMOcopy of original sales receipt, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Framespurchase order, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu invoice showing the date of spectacle lenses Elective Conventional Disposable You receive 15% off balance purchase); • Documentation confirming date of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopesinstallation; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and

Limitations and Exclusions. The Please read these Terms with particular care, as they describe certain exclusions and limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO on liability that may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for arise during the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member provision of the HMO vision care plan so that Your eligibility can be verifiedServices. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxxPLEASE REMEMBER – WE ARE NOT REPRESENTING, WARRANTING OR IN ANY WAY SUGGESTING THAT MASC EXECUTIVE’S JOURNEYCALL IS A REPLACEMENT FOR OR SUPPLEMENT TO THE EMERGENCY SERVICES AND YOUR OWN SAFETY PRECAUTIONS. You may also refer to Your Provider directory or call customer service at the tollWE TRY TO KEEP MASC EXECUTIVE’S JOURNEYCALL UP, BUG-free telephone number on the back of Your identification cardFREE, AND SAFE, BUT YOU USE IT AT YOUR OWN RISK. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locationsWE ARE PROVIDING MASC EXECUTIVE, if desiredJOURNEYCALL "AS IS" WITHOUT ANY EXPRESS OR IMPLIED WARRANTIES INCLUDING, BUT NOT LIMITED TO, IMPLIED WARRANTIES OF MERCHANTABILITY, SATISFACTORY QUALITY, OR FITNESS FOR A PARTICULAR PURPOSE, AND NON- INFRINGEMENT OF ANY THIRD PARTY RIGHTS. HoweverWE DO NOT GUARANTEE THAT MASC EXECUTIVE’S JOURNEYCALL WILL BE SAFE OR SECURE. MASC EXECUTIVE IS NOT RESPONSIBLE FOR THE ACTIONS, complete eyeglasses must be obtained at one timeCONTENT, from one Participating ProviderINFORMATION, OR DATA OF THIRD PARTIES, AND YOU HEREBY RELEASE AND INDEMNIFY AND AGREE TO KEEP INDEMNIFIED NOW AND IN THE FUTURE US, OUR DIRECTORS, OFFICERS, EMPLOYEES, AND AGENTS FROM ANY CLAIMS AND DAMAGES, KNOWN AND UNKNOWN, ARISING OUT OF OR IN ANY WAY CONNECTED WITH ANY CLAIM YOU HAVE AGAINST ANY SUCH THIRD PARTIES. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examinationWE WILL NOT BE LIABLE TO YOU FOR ANY LOST PROFITS, LOSS OF OPPORTUNITY, LOSS OF DATA, OR FOR ANY LOSS OF ECONOMIC USE, NOT FOR ANY CONSEQUENTIAL, SPECIAL, INDIRECT, OR INCIDENTAL DAMAGES ARISING OUT OF OR IN CONNECTION WITH THIS AGREEMENT, EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. Fees charged for services other than a covered vision examination or covered Vision MaterialsOUR AGGREGATE LIABILITY ARISING OUT OF THIS STATEMENT OR MASC EXECUTIVE’S JOURNEYCALL WILL NOT EXCEED THE GREATER OF ONE HUNDRED POUNDS (£100) OR THE AMOUNT YOU HAVE PAID US IN THE PAST TWELVE MONTHS. APPLICABLE LAW MAY NOT ALLOW THE LIMITATION OR EXCLUSION OF LIABILITY OR INCIDENTAL OR CONSEQUENTIAL DAMAGES, and amounts in excess of those payable under this Pediatric Vision Care BenefitSO THE ABOVE LIMITATION OR EXCLUSION MAY NOT APPLY TO YOU. IN SUCH CASES, must be paid in full by You to the ProviderMASC EXECUTIVE, whether or not the Provider participates in the vision care planJOURNEYCALL LIABILITY WILL BE LIMITED TO THE FULLEST EXTENT PERMITTED BY APPLICABLE LAW. These Pediatric Vision Care Benefits may not be combined with any discountNOTWITHSTANDING THE ABOVE TERMS, promotional offeringNOTHING IN THIS AGREEMENT SHALL OR IS INTENDED TO EXCLUDE OR LIMIT OUR LIABILITY TO YOU FOR DEATH, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS andPERSONAL INJURY OR FOR ANY OTHER LIABILITY FOR LOSS WHICH CANNOT BE LAWFULLY EXCLUDED OR LIMITED.

Limitations and Exclusions. Unless modified in writing signed by an officer of SAGE, the Limited Warranties set forth above are the only express warranties (whether written or oral) of SAGE applicable to SAGE’s products and no one is authorized to modify or expand it. Any warranty provided by the Customer to its customers or end-users shall be the sole responsibility of the Customer. The limitations Limited Warranties contained herein are provided to SAGE’s direct customers or to the OEM and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover extend to the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, chartsend-user, or any costs associated with forwarding/mailing copies of Your records other person or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates entity in the vision care planchain of ownership or distribution. These Pediatric Vision Care Benefits may not be combined with any discountTHIS DOCUMENT CONSTITUTES THE EXCLUSIVE WARRANTIES AND REMEDIES PROVIDED BY SAGE. THE WARRANTIES AND REMEDIES CONTAINED IN THIS DOCUMENT ARE EXPRESSLY IN LIEU OF ANY AND ALL OTHER OBLIGATIONS, promotional offeringGUARANTEES AND WARRANTIES, or other group benefit plansWHETHER WRITTEN, ORAL OR IMPLIED BY STATUTE OR AT LAW. Allowances are oneSAGE HEREBY DISCLAIMS ANY AND ALL IMPLIED WARRANTIES INCLUDING MERCHANTABILITY AND FITNESS FOR A PARTICULAR USE AND ANY OTHER OBLIGATION OR LIABILITY NOT EXPRESSLY SET FORTH HEREIN. UNDER NO CIRCUMSTANCES SHALL SAGE BE RESPONSIBLE FOR ANY SPECIAL, PUNITIVE, INDIRECT, INCIDENTAL OR CONSEQUENTIAL DAMAGES (INCLUDING, WITHOUT LIMITATION, THE COST TO REMOVE NON-time use benefits; no remaining balances are carried over to be used laterCONFORMING PRODUCT OR INSTALL REPLACEMENT PRODUCT, LOSS OF PROFITS, HARM TO GOODWILL OR BUSINESS REPUTATION, OR DELAY DAMAGES), WHETHER SUCH CLAIMS ARE BASED IN CONTRACT, WARRANTY, NEGLIGENCE OR STRICT TORT LIABILITY, AND ITS TOTAL LIABILITY SHALL IN ALL INSTANCES BE LIMITED TO REPLACEMENT OF THE DEFECTIVE PRODUCT OR, AT ITS OPTION, REPAIR OF THE DEFECTIVE PRODUCT. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS andTHIS EXCLUSION APPLIES EVEN IF THE REMEDY SET FORTH ABOVE IS DEEMED TO HAVE FAILED OF ITS ESSENTIAL PURPOSE.

Limitations and Exclusions. The Please read these Terms with particular care, as they describe certain exclusions and limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO on liability that may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for arise during the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member provision of the HMO vision care plan so that Your eligibility can be verifiedServices. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxxPLEASE REMEMBER – WE ARE NOT REPRESENTING, WARRANTING OR IN ANY WAY SUGGESTING THAT ZECURE IS A REPLACEMENT FOR OR SUPPLEMENT TO THE EMERGENCY SERVICES AND YOUR OWN SAFETY PRECAUTIONS. You may also refer to Your Provider directory or call customer service at the tollWE TRY TO KEEP ZECURE UP, BUG-free telephone number on the back of Your identification cardFREE, AND SAFE, BUT YOU USE IT AT YOUR OWN RISK. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locationsWE ARE PROVIDING [CLIENT PRODUCT NAME] "AS IS" WITHOUT ANY EXPRESS OR IMPLIED WARRANTIES INCLUDING, if desiredBUT NOT LIMITED TO, IMPLIED WARRANTIES OF MERCHANTABILITY, SATISFACTORY QUALITY, OR FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT OF ANY THIRD PARTY RIGHTS. HoweverWE DO NOT GUARANTEE THAT ZECURE WILL BE SAFE OR SECURE. ZECURE IS NOT RESPONSIBLE FOR THE ACTIONS, complete eyeglasses must be obtained at one timeCONTENT, from one Participating ProviderINFORMATION, OR DATA OF THIRD PARTIES, AND YOU HEREBY RELEASE AND INDEMNIFY AND AGREE TO KEEP INDEMNIFIED NOW AND IN THE FUTURE US, OUR DIRECTORS, OFFICERS, EMPLOYEES, AND AGENTS FROM ANY CLAIMS AND DAMAGES, KNOWN AND UNKNOWN, ARISING OUT OF OR IN ANY WAY CONNECTED WITH ANY CLAIM YOU HAVE AGAINST ANY SUCH THIRD PARTIES. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examinationWE WILL NOT BE LIABLE TO YOU FOR ANY LOST PROFITS, LOSS OF OPPORTUNITY, LOSS OF DATA, OR FOR ANY LOSS OF ECONOMIC USE, NOT FOR ANY CONSEQUENTIAL, SPECIAL, INDIRECT, OR INCIDENTAL DAMAGES ARISING OUT OF OR IN CONNECTION WITH THIS AGREEMENT, EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. Fees charged for services other than a covered vision examination or covered Vision MaterialsOUR AGGREGATE LIABILITY ARISING OUT OF THIS STATEMENT OR [CLIENT PRODUCT NAME] WILL NOT EXCEED THE GREATER OF ONE HUNDRED POUNDS (£100) OR THE AMOUNT YOU HAVE PAID US IN THE PAST TWELVE MONTHS. APPLICABLE LAW MAY NOT ALLOW THE LIMITATION OR EXCLUSION OF LIABILITY OR INCIDENTAL OR CONSEQUENTIAL DAMAGES, and amounts in excess of those payable under this Pediatric Vision Care BenefitSO THE ABOVE LIMITATION OR EXCLUSION MAY NOT APPLY TO YOU. IN SUCH CASES, must be paid in full by You to the ProviderZECURE'S LIABILITY WILL BE LIMITED TO THE FULLEST EXTENT PERMITTED BY APPLICABLE LAW. NOTWITHSTANDING THE ABOVE TERMS, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discountNOTHING IN THIS AGREEMENT SHALL OR IS INTENDED TO EXCLUDE OR LIMIT OUR LIABILITY TO YOU FOR DEATH, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS andPERSONAL INJURY OR FOR ANY OTHER LIABILITY FOR LOSS WHICH CANNOT BE LAWFULLY EXCLUDED OR LIMITED.

Limitations and Exclusions. The limitations and exclusions Any goods or Services provided outside of the explicit scope of those set forth in this section Exhibit are billable at Hill-Rom’s current fee for Service rates with a four (4) hour minimum. Such rates are inclusive of travel and expenses. The warranties stated herein are not transferable and apply only to all pediatric vision benefitsHill-Rom Provided Components and Licensed Software installed by Hill-Rom or an authorized Hill-Rom representative. Although HMO may list THE WARRANTIES STATED ABOVE IN SECTIONS I AND II ARE IN LIEU OF ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. HILL-ROM DOES NOT WARRANT THAT THE OPERATION OF THE PRODUCT OR THE SERVICES PROVIDED HEREUNDER WILL BE ERROR FREE OR UNINTERRUPTED. HILL-ROM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR SPECIAL DAMAGES INCLUDING LOST REVENUES AND LOST PROFITS EVEN IF NOTIFIED IN ADVANCE OF THE POSSIBILITY OF SUCH DAMAGES. HILL-ROM MAKES NO EXPRESS OR IMPLIED REPRESENTATIONS OR WARRANTIES, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE WITH RESPECT TO CENTRAK EQUIPMENT OR CENTRAK SOFTWARE (SET FORTH AT EXHBIT B). HILL-ROM DOES NOT WARRANT THAT THE CENTRAK EQUIPMENT OR CENTRAK SOFTWARE WILL PERFORM ERROR FREE OR UNINTERRUPTED. HILL-ROM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR SPECIAL DAMAGES INCLUDING LOST REVENUES AND LOST PROFITS EVEN IF NOTIFIED IN ADVANCE OF THE POSSIBILITY OF SUCH DAMAGES. Exhibit B applies only if the Proposal reflects a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member purchase of the HMO vision care plan so that Your eligibility can Enhanced Staff Locating module, made available with Voalte Nurse Call. This exhibit may be verifieddisregarded if Customer is not purchasing Enhanced Staff Locating. For Certain Third Party Programs and equipment incorporated in or used with the most current list Product may be subject to the terms and conditions set forth in pass-through provisions or end user license agreements from the third party suppliers of Participating Providers visit such products. CenTrak, Inc. is the website manufacturer of the Enhanced Staff Locating component of the Voalte Nurse Call system. Customer’s use of the CenTrak Equipment and CenTrak Software are subject to the End User License Agreement, warranty and limitations, and mandatory software maintenance pass through provisions set forth here at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at Exhibit B. Exhibit B shall be incorporated into the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locationsAgreement, if desiredCustomer purchases the Enhanced Staff Locating feature. HoweverEXHIBIT B PASS-THROUGH PROVISIONS CENTRAK END USER LICENSE AGREEMENT & WARRANTY THIS END USER LICENSE AGREEMENT (“XXXX”) sets forth the respective rights and responsibilities as between End User and CenTrak, complete eyeglasses must be obtained at one timeInc., from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision MaterialsDelaware corporation (“CenTrak”), and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You relative to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS andCenTrak Software.

Limitations and Exclusions. The limitations and exclusions Any goods or Services provided outside of the explicit scope of those set forth in this section Exhibit are billable at Hill-Rom’s current fee for Service rates with a four (4) hour minimum. Such rates are inclusive of travel and expenses. The warranties stated herein are not transferable and apply only to all pediatric vision benefitsHill-Rom Provided Components and Licensed Software installed by Hill-Rom or an authorized Hill-Rom representative. Although HMO may list a specific THE WARRANTIES STATED ABOVE IN SECTIONS I AND II ARE IN LIEU OF ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. HILL-ROM DOES NOT WARRANT THAT THE OPERATION OF THE PRODUCT OR THE SERVICES PROVIDED HEREUNDER WILL BE ERROR FREE OR UNINTERRUPTED. HILL-ROM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR SPECIAL DAMAGES INCLUDING LOST REVENUES AND LOST PROFITS EVEN IF NOTIFIED IN ADVANCE OF THE POSSIBILITY OF SUCH DAMAGES. HILL-ROM MAKES NO EXPRESS OR IMPLIED REPRESENTATIONS OR WARRANTIES, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE WITH RESPECT TO CENTRAK EQUIPMENT OR CENTRAK SOFTWARE (SET FORTH AT EXHBIT B). XXXX-ROM DOES NOT WARRANT THAT THE CENTRAK EQUIPMENT OR CENTRAK SOFTWARE WILL PERFORM ERROR FREE OR UNINTERRUPTED. HILL-ROM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR SPECIAL DAMAGES INCLUDING LOST REVENUES AND LOST PROFITS EVEN IF NOTIFIED IN ADVANCE OF THE POSSIBILITY OF SUCH DAMAGES. EXHIBIT B BUSINESS ASSOCIATE ADDENDUM WHEREAS, Hill-Rom will perform certain services (the “Services”) to Customer (hereinafter referred to as “Covered Entity” under this Exhibit C) in connection with Hill-Rom’s license, sale and/or service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed Product as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those more particularly described in this benefit;  Replacement the Proposal. Such services may involve the disclosure by Covered Entity to Hill-Rom of lost/stolen eyewear;  Non-prescription certain data which may include Protected Health Information, as that term is defined at 45 C.F.R. § 160.103 (Plano“PHI”) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and;

Limitations and Exclusions. The This Limited Warranty is the only applicable warranty, and ALL IMPLIED WARRANTIES, INCLUDING ANY IMPLIED WAR- RANTY OF MERCHANTABILITY AND/OR FITNESS FOR A PARTICULAR PURPOSE, ARE EXPRESSLY LIMITED TO THE DURATION OF THIS EXPRESS LIMITED WARRANTY. Some states do not allow limitations on how long an im- plied warranty lasts, so the above limitation may not apply to you. To the extent permitted by law, TREDIT EXPRESSLY DIS- CLAIMS ANY AND ALL LIABILITY FOR ANY INCIDENTAL AND CONSEQUENTIAL DAMAGES, INCLUDING, WITHOUT LIMITATION, LOSS OF TIME, INCONVENIENCE, LOSS OF USE OF TRAILER, COSTS OF TOWING OR TRANSPORTA- TION, AND VEHICLE/TRAILER DAMAGE. Some states do not allow the exclusion or limitation of incidental or consequential damages, so the above limita- tion or exclusion may not apply to you. Tredit makes no express claims of expected tire wear. Tire wear can be affected by many variables including, without limitation driving conditions, load, and exclusions tire inflation. Nothing in this section apply warranty is intended to all pediatric vision benefitsbe a representation that tire failures cannot occur. Although HMO may list a specific service as a benefitNo one, HMO will not cover it unless we determine it is necessary for including Tredit employees, representatives, or dealers has the preventionauthority to make or imply any warranties, diagnosispromises or agreements which in any way vary from the terms of this Lim- ited Warranty. Dispute Resolution Any controversy or claim arising out of or relating to this Lim- ited Warranty, care or treatment the sale or use of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, chartsany tire, or any costs associated breach thereof, shall be settled by arbitration administered by the American Arbitration Association in accordance with forwarding/mailing copies its Com- mercial Arbitration Rules, and judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The place of Your records or charts;  arbitration shall be Elkhart, Indiana. This agreement shall be governed by and interpreted in accordance with the laws of the State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described Indiana. The parties acknowledge that this agreement evidences a transaction involving interstate commerce. The Federal Arbitration Act, 9 U.S.C. §2 et seq., also known as the United States Arbitration Act, shall govern the interpretation, enforcement and proceedings pursuant to the arbitration clause in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices agreement. Legal Remedies This warranty gives you specific legal rights, and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You you may also refer have other rights which vary from State to Your Provider directory or call customer service at the tollState. H188ST SERIES FEATURES:    Advanced structure design Strength and long-free telephone number on the back of Your identification cardlasting wear Advanced compound reducing rolling resistance. You may receive Your eye examination and eyeglassesTire Size LR/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount PR Tread Depth ST175/80D13 C/6 8/32 ST185/80D13 C/6 8/32 ST185/80D13 D/8 8/32 ST205/75D14 C/6 8/32 ST205/75D15 C/6 8/32 ST215/75D14 C/6 8/32 Rim Width (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*inches) Out-of-Network Allowance Section Width (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam Inches) Overall Diame- ter (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options Inches) 5.00 6.77 24.41 5.00 7.24 24.65 5.00 7.24 24.80 5.50 7.87 26.50 5.50 7.99 27.13 5.50 7.99 26.97 6.00 8.39 28.70 Maximum Load (added to lens prices above): Tint lbs.) Inflation Pressure (Solid and GradientPSI) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and1360 50 1480 50 1730 65 1760 50 1820 50 1870 50 2540 65

Limitations and Exclusions. The limitations and exclusions Any goods or Services provided outside of the explicit scope of those set forth in this section Exhibit are billable at Hill-Rom’s current fee for Service rates with a four (4) hour minimum. Such rates are inclusive of travel and expenses. The warranties stated herein are not transferable and apply only to all pediatric vision benefitsHill-Rom Provided Components and Licensed Software installed by Hill-Rom or an authorized Hill-Rom representative. Although HMO may list THE WARRANTIES STATED ABOVE IN SECTIONS I AND II ARE IN LIEU OF ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. HILL-ROM DOES NOT WARRANT THAT THE OPERATION OF THE PRODUCT OR THE SERVICES PROVIDED HEREUNDER WILL BE ERROR FREE OR UNINTERRUPTED. HILL-ROM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR SPECIAL DAMAGES INCLUDING LOST REVENUES AND LOST PROFITS EVEN IF NOTIFIED IN ADVANCE OF THE POSSIBILITY OF SUCH DAMAGES. HILL-ROM MAKES NO EXPRESS OR IMPLIED REPRESENTATIONS OR WARRANTIES, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE WITH RESPECT TO CENTRAK EQUIPMENT OR CENTRAK SOFTWARE (SET FORTH AT EXHBIT B). XXXX-ROM DOES NOT WARRANT THAT THE CENTRAK EQUIPMENT OR CENTRAK SOFTWARE WILL PERFORM ERROR FREE OR UNINTERRUPTED. HILL-ROM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR SPECIAL DAMAGES INCLUDING LOST REVENUES AND LOST PROFITS EVEN IF NOTIFIED IN ADVANCE OF THE POSSIBILITY OF SUCH DAMAGES. Exhibit B applies only if the Proposal reflects a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member purchase of the HMO vision care plan so that Your eligibility can Enhanced Staff Locating module, made available with Voalte Nurse Call. This exhibit may be verifieddisregarded if Customer is not purchasing Enhanced Staff Locating. For Certain Third Party Programs and equipment incorporated in or used with the most current list Product may be subject to the terms and conditions set forth in pass-through provisions or end user license agreements from the third party suppliers of Participating Providers visit such products. CenTrak, Inc. is the website manufacturer of the Enhanced Staff Locating component of the Voalte Nurse Call system. Customer’s use of the CenTrak Equipment and CenTrak Software are subject to the End User License Agreement, warranty and limitations, and mandatory software maintenance pass through provisions set forth here at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at Exhibit B. Exhibit B shall be incorporated into the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locationsAgreement, if desiredCustomer purchases the Enhanced Staff Locating feature. HoweverEXHIBIT B PASS-THROUGH PROVISIONS CENTRAK END USER LICENSE AGREEMENT & WARRANTY THIS END USER LICENSE AGREEMENT (“XXXX”) sets forth the respective rights and responsibilities as between End User and CenTrak, complete eyeglasses must be obtained at one timeInc., from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision MaterialsDelaware corporation (“CenTrak”), and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You relative to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS andCenTrak Software.

Limitations and Exclusions. The limitations and exclusions Any goods or Services provided outside of the explicit scope of those set forth in this section Exhibit are billable at Hill-Rom’s current fee for Service rates with a four (4) hour minimum. Such rates are inclusive of travel and expenses. The warranties stated herein are not transferable and apply only to all pediatric vision benefitsHill-Rom Provided Components and Licensed Software installed by Hill-Rom or an authorized Hill-Rom representative. Although HMO may list a specific THE WARRANTIES STATED ABOVE IN SECTIONS I AND II ARE IN LIEU OF ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. HILL-ROM DOES NOT WARRANT THAT THE OPERATION OF THE PRODUCT OR THE SERVICES PROVIDED HEREUNDER WILL BE ERROR FREE OR UNINTERRUPTED. HILL-ROM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR SPECIAL DAMAGES INCLUDING LOST REVENUES AND LOST PROFITS EVEN IF NOTIFIED IN ADVANCE OF THE POSSIBILITY OF SUCH DAMAGES. HILL-ROM MAKES NO EXPRESS OR IMPLIED REPRESENTATIONS OR WARRANTIES, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE WITH RESPECT TO CENTRAK EQUIPMENT OR CENTRAK SOFTWARE (SET FORTH AT EXHBIT B). HILL-ROM DOES NOT WARRANT THAT THE CENTRAK EQUIPMENT OR CENTRAK SOFTWARE WILL PERFORM ERROR FREE OR UNINTERRUPTED. HILL-ROM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR SPECIAL DAMAGES INCLUDING LOST REVENUES AND LOST PROFITS EVEN IF NOTIFIED IN ADVANCE OF THE POSSIBILITY OF SUCH DAMAGES. EXHIBIT B BUSINESS ASSOCIATE ADDENDUM WHEREAS, Hill-Rom will perform certain services (the “Services”) to Customer (hereinafter referred to as “Covered Entity” under this Exhibit C) in connection with Hill-Rom’s license, sale and/or service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed Product as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those more particularly described in this benefit;  Replacement the Proposal. Such services may involve the disclosure by Covered Entity to Hill-Rom of lost/stolen eyewear;  Non-prescription certain data which may include Protected Health Information, as that term is defined at 45 C.F.R. § 160.103 (Plano“PHI”) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and;

Limitations and Exclusions. The Please read these Terms with particular care, as they describe certain exclusions and limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO on liability that may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for arise during the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member provision of the HMO vision care plan so that Your eligibility can be verifiedServices. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxxPLEASE REMEMBER – WE ARE NOT REPRESENTING, WARRANTING OR IN ANY WAY SUGGESTING THAT SECOM Safe IS A REPLACEMENT FOR OR SUPPLEMENT TO THE EMERGENCY SERVICES AND YOUR OWN SAFETY PRECAUTIONS. You may also refer to Your Provider directory WE TRY TO KEEP SECOM Safe UP, BUG-FREE, AND SAFE, BUT YOU USE IT AT YOUR OWN RISK. WE ARE PROVIDING SECOM Safe "AS IS" WITHOUT ANY EXPRESS OR IMPLIED WARRANTIES INCLUDING, BUT NOT LIMITED TO, IMPLIED WARRANTIES OF MERCHANTABILITY, SATISFACTORY QUALITY, OR FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT OF ANY THIRD PARTY RIGHTS. WE DO NOT GUARANTEE THAT SECOM Safe WILL BE SAFE OR SECURE. SECOM GUARDALL NZ LTD or call customer service at the toll-free telephone number on the back of Your identification cardSECOM SAFE IS NOT RESPONSIBLE FOR THE ACTIONS, CONTENT, INFORMATION, OR DATA OF THIRD PARTIES, AND YOU HEREBY RELEASE AND INDEMNIFY AND AGREE TO KEEP INDEMNIFIED NOW AND IN THE FUTURE US, OUR DIRECTORS, OFFICERS, EMPLOYEES, AND AGENTS FROM ANY CLAIMS AND DAMAGES, KNOWN AND UNKNOWN, ARISING OUT OF OR IN ANY WAY CONNECTED WITH ANY CLAIM YOU HAVE AGAINST ANY SUCH THIRD PARTIES. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locationsWE WILL NOT BE LIABLE TO YOU FOR ANY LOST PROFITS, if desiredLOSS OF OPPORTUNITY, LOSS OF DATA, OR FOR ANY LOSS OF ECONOMIC USE, NOT FOR ANY CONSEQUENTIAL, SPECIAL, INDIRECT, OR INCIDENTAL DAMAGES ARISING OUT OF OR IN CONNECTION WITH THIS AGREEMENT, EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. HoweverOUR AGGREGATE LIABILITY ARISING OUT OF THIS STATEMENT OR SECOM Safe WILL NOT EXCEED THE GREATER OF ONE HUNDRED NZ DOLLARS ($100)] OR THE AMOUNT YOU HAVE PAID US IN THE PAST TWELVE MONTHS OR THE LESSER AMOUNT. APPLICABLE LAW MAY NOT ALLOW THE LIMITATION OR EXCLUSION OF LIABILITY OR INCIDENTAL OR CONSEQUENTIAL DAMAGES, complete eyeglasses must be obtained at one timeSO THE ABOVE LIMITATION OR EXCLUSION MAY NOT APPLY TO YOU. IN SUCH CASES, from one Participating ProviderSECOM Safe's LIABILITY WILL BE LIMITED TO THE FULLEST EXTENT PERMITTED BY APPLICABLE LAW. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision MaterialsNOTWITHSTANDING THE ABOVE TERMS, and amounts in excess of those payable under this Pediatric Vision Care BenefitNOTHING IN THIS AGREEMENT SHALL OR IS INTENDED TO EXCLUDE OR LIMIT OUR LIABILITY TO YOU FOR DEATH, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS andPERSONAL INJURY OR FOR ANY OTHER LIABILITY FOR LOSS WHICH CANNOT BE LAWFULLY EXCLUDED OR LIMITED.

Limitations and Exclusions. The In addition to any other limitations and exclusions in set forth herein, Xxxxxxx ENC is not responsible for, and this section apply W arranty does not cover: • failures due to all pediatric vision benefits. Although HMO may list abuse, misuse, accident, unauthorized alteration or repair, improper installation (whether or not by a specific Samyung ENC-certified service as a benefitagent), HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care shipping damage or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered servicecorrosion;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any • costs associated with forwardingroutine system checkouts, alignment/mailing copies calibration, seatrials or commissioning; • repair or replacement of Your records consumable items, including, without limitation, fuses, batteries, drive belts, radar mixer diodes, snap-in impeller carriers, impellers, impeller bearings and impeller shafts; • differences in material, coloring or charts;  State size that may exist between actual products and the pictures or territorial taxes on vision services performed;  Medical treatment descriptions of eye disease such products in our advertising, advertising literature or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses Internet; • products purchased by a customer from a Participating Provider other than United States dealer via the one who performed Your eye examination. Fees charged for services other than a covered vision examination Internet if such products were not delivered and installed within the United States; or covered Vision Materials, and amounts in excess • the replacement of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due missing components from the Memberpackage of any product purchased through an online auction site. Other Conditions This W arranty is fully transferable provided that you furnish the original proof of purchase to Samyung ENC or to an authorized Samyung ENC distributor. This Warranty is void if the label bearing the serial number has been removed or defaced. TO THE EXTENT CONSISTENT W ITH STATE AND FEDERAL LAW, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMOTHE FOREGOING WARRANTY IS SAMYUNG ENC'S SOLE WARRANTY AND IS APPLICABLE ONLY TO NEW PRODUCTS PURCHASED IN THE UNITED STATES OF AMERICA. THE PROVISIONS OF THIS WARRANTY ARE IN LIEU OF ANY OTHER WRITTEN WARRANTY, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: ExaminationWHETHER EXPRESSED OR IMPLIED, Contact Lenses Lenses/FramesWRITTEN OR ORAL, or Once every Calendar Year Standard PlasticINCLUDING ANY WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. THE LIABILITY OF SAMYUNG ENC TO A CUSTOMER UNDER THIS WARRANTY, GlassWHETHER FOR BREACH OF CONTRACT, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coatingTORT, fashion and gradient tintingBREACH OF STATUTORY DUTY OR OTHERWISE SHALL IN NO EVENT SHALL EXCEED AN AMOUNT EQUAL TO THE MANUFACTURER’S SUGGESTED RETAIL PRICE OF THE PRODUCT GIVING RISE TO SUCH LIABILITY AND IN NO EVENT SHALL SAMYUNG ENC BE LIABLE FOR SPECIAL, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devicesINCIDENTAL, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS andCONSEQUENTIAL OR INDIRECT DAMAGES.

Limitations and Exclusions. The limitations This warranty applies only to products manufactured for GROHE after September 1, 2016 and exclusions in this section purchased by the original consumer-purchaser in, and installed in, either the United States, Canada, or Mexico. This warranty applies only if the product was properly installed, mounted, operated, cared for, and cleaned, irrespective of whether installation and/or mounting is performed by a qualified specialist fitter or the original consumer-purchaser. This warranty shall not apply to all pediatric vision benefitsany products or spare parts: not properly installed, cared for, maintained, or repaired in accordance with GROHE’s instructions, valid water regulations, and/or best plumbing practices; defective out of the box; not installed or removed; damaged due to incorrect operation, handling, transportation, installation, breakage of fragile parts, or missing or incorrect maintenance; repaired or maintained by or with spare parts other than original GROHE spare parts; scratched; used as displays; that are second hand; with affected consumables (such as batteries, filters, filter cartridges, aerators or batteries) or material subject to wear and tear (such as seals); damaged due to environmental influences or circumstances (such as chemicals and cleaning agents, pressure in the line, or voltage), lime scale or disruptions to ice and/or lime; damaged due to willfulness or negligence by the end customer or a third- party; or purchased on auction sites (either consumer-to-consumer or second hand). Although HMO With the exception of missing component parts, notice of which must be given within thirty (30) days of purchase, notification must be given within a reasonable time after discovery of the defect, but no later than expiration of the warranty period. This warranty is non-transferable. THIS WARRANTY IS IN LIEU OF ALL OTHER WARRANTIES, INCLUDING ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. XXXXX WILL NOT BE LIABLE FOR ANY LOSS, DAMAGE, EXPENSE OR INCIDENTAL OR CONSEQUENTIAL DAMAGES OF ANY KIND, WHETHER BASED ON WARRANTY, CONTRACT OR NEGLIGENCE AND ARISING IN CONNECTION WITH THE SALE, USE OR REPAIR OF ANY PRODUCTS OR PARTS. SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF CONSEQUENTIAL DAMAGE OR LIMITATIONS ON HOW LONG AN IMPLIED WARRANTY LASTS, SO THE ABOVE LIMITATIONS OR EXCLUSIONS MAY NOT APPLY. This warranty gives the original consumer-purchaser specific legal rights which may list vary from country to country, state to state, or province to province. In some countries, states, or provinces, the exclusion or limitation of incidental or consequential damages is not allowed, so those exclusions may not apply. UNLESS OTHERWISE CONTRARY TO THE LAW GOVERNING THE PURCHASE, GROHE’S LIABILITY WILL NOT EXCEED THE CONTRACT PRICE FOR THE PRODUCT CLAIMED TO BE DEFECTIVE. SUBMITTING A WARRANTY CLAIM: To submit a specific service as a benefitwarranty claim, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care original purchaser-owner should submit the information listed below to GROHE Customer Service at XX-xxxxxxxxxxx@xxxxx.xxx or treatment of a covered conditionthrough our website at xxxxx://xxx.xxxxx.xxx/us/5685/services- for-you/warranties/. Telephone inquiries may be directed to (000) 000-0000. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered serviceProduct/model number;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) OutProof-of-Network Allowance purchase (maximum reimbursement amount payable by HMOcopy of original sales receipt, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Framespurchase order, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu invoice showing the date of spectacle lenses Elective Conventional Disposable You receive 15% off balance purchase);  Documentation confirming date of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopesinstallation; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and

Limitations and Exclusions. The limitations and exclusions Any goods or Services provided outside of the explicit scope of those set forth in this section Exhibit are billable at Hill-Rom’s current fee for Service rates with a four (4) hour minimum. Such rates are inclusive of travel and expenses. The warranties stated herein are not transferable and apply only to all pediatric vision benefitsHill-Rom Provided Components and Licensed Software installed by Hill-Rom or an authorized Hill-Rom representative. Although HMO may list THE WARRANTIES STATED HEREIN ARE IN LIEU OF ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. HILL-ROM DOES NOT WARRANT THAT THE OPERATION OF THE PRODUCT OR THE SERVICES PROVIDED HEREUNDER WILL BE ERROR FREE OR UNINTERRUPTED. HILL-ROM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR SPECIAL DAMAGES INCLUDING LOST REVENUES AND LOST PROFITS EVEN IF NOTIFIED IN ADVANCE OF THE POSSIBILITY OF SUCH DAMAGES. HILL-ROM MAKES NO EXPRESS OR IMPLIED REPRESENTATIONS OR WARRANTIES, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE WITH RESPECT TO CENTRAK EQUIPMENT OR CENTRAK SOFTWARE (SET FORTH AT EXHBIT B). HILL-ROM DOES NOT WARRANT THAT THE CENTRAK EQUIPMENT OR CENTRAK SOFTWARE WILL PERFORM ERROR FREE OR UNINTERRUPTED. HILL-ROM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE OR SPECIAL DAMAGES INCLUDING LOST REVENUES AND LOST PROFITS EVEN IF NOTIFIED IN ADVANCE OF THE POSSIBILITY OF SUCH DAMAGES. Exhibit B applies only if the Proposal reflects a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following:  Any vision service, treatment or materials not specifically listed as a covered service;  Services and materials that are experimental or investigational;  Services and materials that are rendered prior to Your effective date;  Services and materials incurred after the termination date of Your coverage unless otherwise indicated;  Services and materials not meeting accepted standards of optometric practice;  Services and materials resulting from Your failure to comply with professionally prescribed treatment;  Telephone consultations;  Any charges for failure to keep a scheduled appointment;  Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;  Office infection control charges;  Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts;  State or territorial taxes on vision services performed;  Medical treatment of eye disease or injury;  Visual therapy;  Special lens designs or coatings other than those described in this benefit;  Replacement of lost/stolen eyewear;  Non-prescription (Plano) lenses;  Non-prescription sunglasses  Two pairs of eyeglasses in lieu of bifocals;  Services not performed by licensed personnel;  Prosthetic devices and services;  Insurance of contact lenses;  Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption;  Orthoptic or vision training; Aniseikonic spectacle lenses. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member purchase of the HMO vision care plan so that Your eligibility can Enhanced Staff Locating module, made available with NaviCare Nurse Call. This exhibit may be verifieddisregarded if Customer is not purchasing Enhanced Staff Locating. For Certain Third Party Programs and equipment incorporated in or used with the most current list Product may be subject to the terms and conditions set forth in pass-through provisions or end user license agreements from the third party suppliers of Participating Providers visit such products. CenTrak, Inc. is the website manufacturer of the Enhanced Staff Locating component of the NaviCare Nurse Call system. Customer’s use of the CenTrak Equipment and CenTrak Software are subject to the End User License Agreement, warranty and limitations, and mandatory software maintenance pass through provisions set forth here at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at Exhibit B. Exhibit B shall be incorporated into the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locationsAgreement, if desiredCustomer purchases the Enhanced Staff Locating feature. HoweverEXHIBIT B PASS-THROUGH PROVISIONS CENTRAK END USER LICENSE AGREEMENT & WARRANTY THIS END USER LICENSE AGREEMENT (“XXXX”) sets forth the respective rights and responsibilities as between End User and CenTrak, complete eyeglasses must be obtained at one timeInc., from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision MaterialsDelaware corporation (“CenTrak”), and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You relative to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS andCenTrak Software.