Common use of Network Benefits Clause in Contracts

Network Benefits. Benefits for Vision Care Services are determined based on the negotiated contract fee between us and the Vision Care Provider. Our negotiated rate with the Vision Care Provider is ordinarily lower than the Vision Care Provider's billed charge. Payment Information Annual Deductible Unless otherwise stated, Benefits for adult Vision Care Services provided under this section are not subject to any Annual Deductible stated in the Covered Health Care Services Schedule of Benefits. Vision Out-of-Pocket Limit - any amount you pay in Co-insurance for Vision Care Services under this section applies to the Out-of-Pocket Limit stated in the Covered Health Care Services Schedule of Benefits. Any amount you pay in Co-payments for Vision Care Services under this section applies to the Out-of-Pocket Limit stated in the Covered Health Care Services Schedule of Benefits. Benefits Information Table Vision Care Service What Is the Frequency of Service? Network Benefit - The Amount You Pay Based on the Contracted Rate Routine Vision Exam or Refraction only in lieu of a complete exam for Covered Persons 19 years of age and older Once every 12 months. None per exam. Not subject to payment of the Annual Deductible. Retinal Photography Once every 12 months. Copayment of $39 Not subject to payment of the Annual Deductible. Eyeglass Lenses Once every 12 months. • Single Vision Co-payment of $25 Not subject to payment of the Annual Deductible. • Bifocal Co-payment of $25 Not subject to payment of the Annual Deductible. • Trifocal Co-payment of $25 Not subject to payment of the Annual Deductible. • Lenticular Co-payment of $25 Vision Care Service What Is the Frequency of Service? Network Benefit - The Amount You Pay Based on the Contracted Rate Not subject to payment of the Annual Deductible. Optional Lens Extras* *Coverage for some Optional Lens Extras, which may include progressive lenses, may be included with eyeglass packages offered at some Network locations. Once every 12 months. Standard Scratch Coating None Not subject to payment of the Annual Deductible. Eyeglass Frames Up to $130 Once every 12 months. None Not subject to payment of the Annual Deductible. Contact Lenses* *If Contact Lenses that are not on the Formulary are prescribed; the member will be responsible for the Contact Lens Fitting and Evaluation -Coverage for Covered Contact Lens Formulary will not apply at Walmart, Sam's Club, and Costco locations. Other Network locations may not offer Formulary contact lenses. In those cases, your allowance for Contact Lenses that are not on the Formulary will apply. Once every 12 months. Contact Lenses Formulary Up to 4 boxes (In lieu of glasses) Includes Fitting and Evaluation Co-payment of $25 Not subject to payment of the Annual Deductible. Contact Lenses Non-Formulary (In lieu of glasses) Up to $105 allowance None Not subject to payment of the Annual Deductible. Policy Table of Contents Section 1: Covered Health Care Services 9 Section 2: Exclusions and Limitations 29 Section 3: When Coverage Begins and Premiums 32 Section 4: When Coverage Ends 40 Section 5: How to File a Claim 43 Section 6: Questions, Complaints and Appeals 45 Section 7: General Legal Provisions 53 Section 8: Defined Terms 59 Section 9: Coordination of Benefits 74 Section 10: Outpatient Prescription Drugs 79 Section 11: Pediatric Dental Care Services 88 Section 12: Pediatric Vision Care Services 93 Section 13: Adult Dental Care Services 98 Section 14: Adult Vision Care Services 103 Amendment: Off-Exchange Qualified Health Plan 106 Section 1: Covered Health Care Services‌ When Are Benefits Available for Covered Health Care Services? Benefits are available only when all of the following are true: • The health care service, including supplies or Pharmaceutical Products, is only a Covered Health Care Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered Health Care Service in Section 8: Defined Terms.) • You receive Covered Health Care Services while this Policy is in effect. • You receive Covered Health Care Services prior to the date that any of the individual termination conditions listed in Section 4: When Coverage Ends occurs. • The person who receives Covered Health Care Services is a Covered Person and meets all eligibility requirements. The fact that a Physician or other provider has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment for a Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms does not mean that the procedure or treatment is a Covered Health Care Service under this Policy. This section describes Covered Health Care Services for which Benefits are available. Please refer to the attached Schedule of Benefits for details about: • The amount you must pay for these Covered Health Care Services (including any Annual Deductible, Co- payment and/or Co-insurance). • Any limit that applies to these Covered Health Care Services (including visit, day and dollar limits on services). • Any limit that applies to the portion of the Allowed Amount or the Recognized Amount when applicable, you are required to pay in a year (Out-of-Pocket Limit). • Any responsibility you have for obtaining prior authorization or notifying us. Please note that in listing services or examples, when we say "this includes," it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list "is limited to."

Network Benefits. Members will have coverage for a Routine Eye Examination according to the terms of Schedule of Vision Benefits and as described below. In addition to the Routine Eye Examination, Members may have coverage for materials or laser vision correction services, as described below. The Schedule of Vision Care Services are determined based Benefits will state if the Member has coverage for materials and laser vision correction services. Routine Eye Health Examination After Member’s payment of any applicable copayment stated on the negotiated contract fee between us and Schedule of Vision Benefits, the Vision Care ProviderCompany will cover one Routine Eye Health Examination. Our negotiated rate with Covered Routine Eye Health Examinations will include dilation of eye pupils when professionally indicated. Routine Eye Health Examinations will be limited to the Vision Care Provider is ordinarily lower than the Vision Care Provider's billed charge. Payment Information Annual Deductible Unless otherwise stated, Benefits for adult Vision Care Services provided under this section are not subject to any Annual Deductible frequency stated in the Covered Health Care Services Schedule of Vision Benefits. Materials Prescription Spectacle Lens for Each of the Member’s Eyes After Member’s payment of any applicable copayment, the Company will cover one prescription Spectacle Lens for each of the Member’s eyes, as stated in the Schedule of Vision OutBenefits. The type of lens materials covered will be explained in the Schedule of Vision Benefits. Prescription Spectacle Lens coverage will be limited to the frequency stated in the Schedule of Vision Benefits. The Member may be able to enhance the Spectacle Lenses covered above at discounted prices. The Schedule of Vision Benefits may include discounted prices for some special types of lens materials and other enhancements. Any available enhancement options are not to be considered coverage under this Benefit Plan. Eyeglass Frames After Member’s payment of any applicable copayment stated in the Schedule of Vision Benefits, the Company will cover one eyeglass frame, up to any maximum allowance specified in the Schedule of Vision Benefits. Certain private practice Participating Providers carry the Xxxxx Vision Frame Collection, which the Member can get with little or no out-of-Pocket Limit - any amount you pay in Co-insurance for Vision Care Services under this section applies to the Out-of-Pocket Limit pocket costs, as stated in the Covered Health Care Services Schedule of Vision Benefits. Any amount you pay in Co-payments To know which Providers carry the Frame Collection, please visit our website at xxx.xxxxxx.xxx to search for the Xxxxx Vision Care Services under this section applies Providers near You. All Eyeglass Frames coverage will be limited to the Out-of-Pocket Limit frequency stated in the Covered Health Care Services Schedule of Vision Benefits. Prescription Contact Lenses After Member’s payment of any applicable copayment stated in the Schedule of Vision Benefits, the Company will cover one prescription Contact Lens for each of the Member’s eyes, up to the maximum allowance indicated in the Schedule of Vision Benefits. The Schedule of Vision Benefits Information Table Vision Care Service What Is will also indicate if the Frequency of Service? Network Benefit - The Amount You Pay Based on the Contracted Rate Routine Vision Exam or Refraction only Contact Lenses coverage will be in lieu of a complete exam for Covered Persons 19 years or in addition to eyeglasses. If the Contact Lenses coverage is “in lieu of age eyeglasses” it means that, within the frequency period stated in the Schedule, the Member may only choose one of either prescription Spectacle Lenses and older Once every 12 months. None per exam. Not subject to payment of the Annual Deductible. Retinal Photography Once every 12 months. Copayment of $39 Not subject to payment of the Annual Deductible. an Eyeglass Lenses Once every 12 months. • Single Vision Co-payment of $25 Not subject to payment of the Annual Deductible. • Bifocal Co-payment of $25 Not subject to payment of the Annual Deductible. • Trifocal Co-payment of $25 Not subject to payment of the Annual Deductible. • Lenticular Co-payment of $25 Vision Care Service What Is the Frequency of Service? Network Benefit - The Amount You Pay Based on the Contracted Rate Not subject to payment of the Annual Deductible. Optional Lens Extras* *Coverage for some Optional Lens ExtrasFrame, which may include progressive lenses, may be included with eyeglass packages offered at some Network locations. Once every 12 months. Standard Scratch Coating None Not subject to payment of the Annual Deductible. Eyeglass Frames Up to $130 Once every 12 months. None Not subject to payment of the Annual Deductible. or Contact Lenses* *, but not both. If to the contrary, the Contact Lenses coverage is “in addition to eyeglasses”, it means that are not on the Formulary are prescribed; the member will be responsible for the Contact Lens Fitting Member may choose prescription Spectacle Lenses and Evaluation -Coverage for Covered Contact Lens Formulary will not apply at Walmart, Sam's Cluban Eyeglass Frame, and Costco locations. Other Network locations may not offer Formulary contact lenses. In those cases, your allowance for Contact Lenses that are not on within the Formulary will applysame frequency period.‌‌‌‌‌ 3. Once every 12 monthsB. 1. Contact Lenses Formulary Up to 4 boxes (In lieu of glasses) Includes Fitting and Evaluation Co-payment of $25 Not subject to payment of the Annual Deductible2. Contact Lenses Non-Formulary (In lieu of glasses) Up to $105 allowance None Not subject to payment of the Annual Deductible. Policy Table of Contents Section 1: Covered Health Care Services 9 Section 2: Exclusions and Limitations 29 Section 3: When Coverage Begins and Premiums 32 Section 4: When Coverage Ends 40 Section 5: How to File a Claim 43 Section 6: Questions, Complaints and Appeals 45 Section 7: General Legal Provisions 53 Section 8: Defined Terms 59 Section 9: Coordination of Benefits 74 Section 10: Outpatient Prescription Drugs 79 Section 11: Pediatric Dental Care Services 88 Section 12: Pediatric Vision Care Services 93 Section 13: Adult Dental Care Services 98 Section 14: Adult Vision Care Services 103 Amendment: Off-Exchange Qualified Health Plan 106 Section 1: Covered Health Care Services‌ When Are Benefits Available for Covered Health Care Services? Benefits are available only when all of the following are true: • The health care service, including supplies or Pharmaceutical Products, is only a Covered Health Care Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered Health Care Service in Section 8: Defined Terms.) • You receive Covered Health Care Services while this Policy is in effect. • You receive Covered Health Care Services prior to the date that any of the individual termination conditions listed in Section 4: When Coverage Ends occurs. • The person who receives Covered Health Care Services is a Covered Person and meets all eligibility requirements. The fact that a Physician or other provider has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment for a Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms does not mean that the procedure or treatment is a Covered Health Care Service under this Policy. This section describes Covered Health Care Services for which Benefits are available. Please refer to the attached Schedule of Benefits for details about: • The amount you must pay for these Covered Health Care Services (including any Annual Deductible, Co- payment and/or Co-insurance). • Any limit that applies to these Covered Health Care Services (including visit, day and dollar limits on services). • Any limit that applies to the portion of the Allowed Amount or the Recognized Amount when applicable, you are required to pay in a year (Out-of-Pocket Limit). • Any responsibility you have for obtaining prior authorization or notifying us. Please note that in listing services or examples, when we say "this includes," it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list "is limited to."

Network Benefits. Members will have coverage for a Routine Eye Examination according to the terms of Schedule of Vision Benefits and as described below. In addition to the Routine Eye Examination, Members may have coverage for materials or laser vision correction services, as described below. The Schedule of Vision Care Services are determined based Benefits will state if the Member has coverage for materials and laser vision correction services. Routine Eye Health Examination After Member’s payment of any applicable copayment stated on the negotiated contract fee between us and Schedule of Vision Benefits, the Vision Care ProviderCompany will cover one Routine Eye Health Examination. Our negotiated rate with Covered Routine Eye Health Examinations will include dilation of eye pupils when professionally indicated. Routine Eye Health Examinations will be limited to the Vision Care Provider is ordinarily lower than the Vision Care Provider's billed charge. Payment Information Annual Deductible Unless otherwise stated, Benefits for adult Vision Care Services provided under this section are not subject to any Annual Deductible frequency stated in the Covered Health Care Services Schedule of Vision Benefits. Materials Prescription Spectacle Lens for Each of the Member’s Eyes After Member’s payment of any applicable copayment, the Company will cover one prescription Spectacle Lens for each of the Member’s eyes, as stated in the Schedule of Vision OutBenefits. The type of lens materials covered will be explained in the Schedule of Vision Benefits. Prescription Spectacle Lens coverage will be limited to the frequency stated in the Schedule of Vision Benefits. The Member may be able to enhance the Spectacle Lenses covered above at discounted prices. The Schedule of Vision Benefits may include discounted prices for some special types of lens materials and other enhancements. Any available enhancement options are not to be considered coverage under this Benefit Plan. Eyeglass Frames After Member’s payment of any applicable copayment stated in the Schedule of Vision Benefits, the Company will cover one eyeglass frame, up to any maximum allowance specified in the Schedule of Vision Benefits. Certain private practice Participating Providers carry the Xxxxx Vision Frame Collection, which the Member can get with little or no out-of-Pocket Limit - any amount you pay in Co-insurance for Vision Care Services under this section applies to the Out-of-Pocket Limit pocket costs, as stated in the Covered Health Care Services Schedule of Vision Benefits. Any amount you pay in Co-payments To know which Providers carry the Frame Collection, please visit our website at xxx.xxxxxx.xxx to search for the Xxxxx Vision Care Services under this section applies Providers near You. All Eyeglass Frames coverage will be limited to the Out-of-Pocket Limit frequency stated in the Covered Health Care Services Schedule of Vision Benefits. Prescription Contact Lenses After Member’s payment of any applicable copayment stated in the Schedule of Vision Benefits, the Company will cover one prescription Contact Lens for each of the Member’s eyes, up to the maximum allowance indicated in the Schedule of Vision Benefits. The Schedule of Vision Benefits Information Table Vision Care Service What Is will also indicate if the Frequency of Service? Network Benefit - The Amount You Pay Based on the Contracted Rate Routine Vision Exam or Refraction only Contact Lenses coverage will be in lieu of a complete exam or in addition to eyeglasses. If the Contact Lenses coverage is in lieu of eyeglasses it means that, within the frequency period stated in the Schedule, the Member may only choose one of either prescription Spectacle Lenses and an Eyeglass Frame, or Contact Lenses, but not both. If to the contrary, the Contact Lenses coverage is in addition to eyeglasses, it means that the Member may choose prescription Spectacle Lenses and an Eyeglass Frame, and Contact Lenses within the same frequency period.‌‌‌‌‌ Laser Vision Correction Services Laser vision corrections are surgical procedures to correct vision problems such as nearsightedness, farsightedness and astigmatism. Laser vision corrections will only be covered if they are included in the Schedule of Vision Benefits. Members will have coverage for Covered Persons 19 years the specific laser vision correction procedures stated in the Schedule of age Vision Benefits, and older Once every 12 months. None per exam. Not subject to payment of the Annual Deductiblecost sharing specified. Retinal Photography Once every 12 monthsAuthorization must be obtained prior to surgery. Copayment of $39 Not subject The Member or attending Provider must send a completed request to payment of the Annual Deductible. Eyeglass Lenses Once every 12 months. • Single Xxxxx Vision Co-payment of $25 Not subject to payment of the Annual Deductible. • Bifocal Co-payment of $25 Not subject to payment of the Annual Deductible. • Trifocal Co-payment of $25 Not subject to payment of the Annual Deductible. • Lenticular Co-payment of $25 Vision Care Service What Is the Frequency of Service? Network Benefit - The Amount You Pay Based on the Contracted Rate Not subject to payment of the Annual Deductible. Optional Lens Extras* *Coverage for some Optional Lens Extras, which may include progressive lenses, may be included with eyeglass packages offered at some Network locations. Once every 12 months. Standard Scratch Coating None Not subject to payment of the Annual Deductible. Eyeglass Frames Up to $130 Once every 12 months. None Not subject to payment of the Annual Deductible. Contact Lenses* *If Contact Lenses that are not on the Formulary are prescribed; the member will be responsible for the Contact Lens Fitting and Evaluation -Coverage for Covered Contact Lens Formulary will not apply at Walmart, Sam's Club, and Costco locations. Other Network locations may not offer Formulary contact lenses. In those cases, your allowance for Contact Lenses that are not on the Formulary will apply. Once every 12 months. Contact Lenses Formulary Up to 4 boxes (In lieu of glasses) Includes Fitting and Evaluation Co-payment of $25 Not subject to payment of the Annual Deductible. Contact Lenses Non-Formulary (In lieu of glasses) Up to $105 allowance None Not subject to payment of the Annual Deductible. Policy Table of Contents Section 1: Covered Health Care Services 9 Section 2: Exclusions and Limitations 29 Section 3: When Coverage Begins and Premiums 32 Section 4: When Coverage Ends 40 Section 5: How to File a Claim 43 Section 6: Questions, Complaints and Appeals 45 Section 7: General Legal Provisions 53 Section 8: Defined Terms 59 Section 9: Coordination of Benefits 74 Section 10: Outpatient Prescription Drugs 79 Section 11: Pediatric Dental Care Services 88 Section 12: Pediatric Vision Care Services 93 Section 13: Adult Dental Care Services 98 Section 14: Adult Vision Care Services 103 Amendment: Off-Exchange Qualified Health Plan 106 Section 1: Covered Health Care Services‌ When Are Benefits Available for Covered Health Care Services? Benefits are available only when all of the following are true: • The health care service, including supplies or Pharmaceutical Products, is only a Covered Health Care Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered Health Care Service in Section 8: Defined Terms.) • You receive Covered Health Care Services while this Policy is in effect. • You receive Covered Health Care Services prior to the date that any of initial evaluation. If the individual termination conditions listed in Section 4: When Coverage Ends occurs. • The person who receives Covered Health Care Services required Authorization is a Covered Person and meets all eligibility requirements. The fact that a Physician or other provider has performed or prescribed a procedure or treatmentnot obtained, or the fact that it may entire charge for such services will be the only available treatment for Member’s responsibility. Surgery must be performed within the time frame from the preoperative examination stated in the Schedule of Vision Benefits. If a Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms Member does not mean obtain the surgery within this time period and another pre-operative examination is necessary, the cost of that the procedure or treatment is a Covered Health Care Service examination will not be covered under this PolicyBenefit Plan. This section describes Covered Health Care Services If according to the Schedule of Vision Benefits the Member’s plan does not cover Laser Vision Correction Services, Members could have a discount for which Benefits are availablesuch services through Xxxxx Vision. Please refer to the attached Schedule of Benefits ask Xxxxx Vision for details about: • The amount you must pay for these Covered Health Care Services (including any Annual Deductible, Co- payment and/or Co-insurance). • Any limit that applies to these Covered Health Care Services (including visit, day and dollar limits on services). • Any limit that applies to the portion of the Allowed Amount or the Recognized Amount when applicable, you are required to pay in a year (Out-of-Pocket Limit). • Any responsibility you have for obtaining prior authorization or notifying us. Please note that in listing services or examples, when we say "this includes," it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list "is limited todetails."

Network Benefits. Members will have coverage for a Routine Eye Examination according to the terms of Schedule of Vision Benefits and as described below. In addition to the Routine Eye Examination, Members may have coverage for materials or laser vision correction services, as described below. The Schedule of Vision Care Services are determined based Benefits will state if the Member has coverage for materials and laser vision correction services. Routine Eye Health Examination After Member’s payment of any applicable copayment stated on the negotiated contract fee between us and Schedule of Vision Benefits, the Vision Care ProviderCompany will cover one Routine Eye Health Examination. Our negotiated rate with Covered Routine Eye Health Examinations will include dilation of eye pupils when professionally indicated. Routine Eye Health Examinations will be limited to the Vision Care Provider is ordinarily lower than the Vision Care Provider's billed charge. Payment Information Annual Deductible Unless otherwise stated, Benefits for adult Vision Care Services provided under this section are not subject to any Annual Deductible frequency stated in the Covered Health Care Services Schedule of Vision Benefits. Materials Prescription Spectacle Lens for Each of the Member’s Eyes After Member’s payment of any applicable copayment, the Company will cover one prescription Spectacle Lens for each of the Member’s eyes, as stated in the Schedule of Vision OutBenefits. The type of lens materials covered will be explained in the Schedule of Vision Benefits. Prescription Spectacle Lens coverage will be limited to the frequency stated in the Schedule of Vision Benefits. The Member may be able to enhance the Spectacle Lenses covered above at discounted prices. The Schedule of Vision Benefits may include discounted prices for some special types of lens materials and other enhancements. Any available enhancement options are not to be considered coverage under this Benefit Plan. Eyeglass Frames After Member’s payment of any applicable copayment stated in the Schedule of Vision Benefits, the Company will cover one eyeglass frame, up to any maximum allowance specified in the Schedule of Vision Benefits. Certain private practice Participating Providers carry the Xxxxx Vision Frame Collection, which the Member can get with little or no out-of-Pocket Limit - any amount you pay in Co-insurance for Vision Care Services under this section applies to the Out-of-Pocket Limit pocket costs, as stated in the Covered Health Care Services Schedule of Vision Benefits. Any amount you pay in Co-payments To know which Providers carry the Frame Collection, please visit our website at xxx.xxxxxx.xxx to search for the Xxxxx Vision Care Services under this section applies Providers near You. All Eyeglass Frames coverage will be limited to the Out-of-Pocket Limit frequency stated in the Covered Health Care Services Schedule of Vision Benefits. Prescription Contact Lenses After Member’s payment of any applicable copayment stated in the Schedule of Vision Benefits, the Company will cover one prescription Contact Lens for each of the Member’s eyes, up to the maximum allowance indicated in the Schedule of Vision Benefits. The Schedule of Vision Benefits Information Table Vision Care Service What Is will also indicate if the Frequency of Service? Network Benefit - The Amount You Pay Based on the Contracted Rate Routine Vision Exam or Refraction only Contact Lenses coverage will be in lieu of a complete exam or in addition to eyeglasses. If the Contact Lenses coverage is “in lieu of eyeglasses” it means that, within the frequency period stated in the Schedule, the Member may only choose one of either prescription Spectacle Lenses and an Eyeglass Frame, or Contact Lenses, but not both. If to the contrary, the Contact Lenses coverage is “in addition to eyeglasses”, it means that the Member may choose prescription Spectacle Lenses and an Eyeglass Frame, and Contact Lenses within the same frequency period. Laser Vision Correction Services Laser vision corrections are surgical procedures to correct vision problems such as nearsightedness, farsightedness and astigmatism. Laser vision corrections will only be covered if they are included in the Schedule of Vision Benefits. Members will have coverage for Covered Persons 19 years the specific laser vision correction procedures stated in the Schedule of age Vision Benefits, and older Once every 12 months. None per exam. Not subject to payment of the Annual Deductiblecost sharing specified. Retinal Photography Once every 12 monthsAuthorization must be obtained prior to surgery. Copayment of $39 Not subject The Member or attending Provider must send a completed request to payment of the Annual Deductible. Eyeglass Lenses Once every 12 months. • Single Xxxxx Vision Co-payment of $25 Not subject to payment of the Annual Deductible. • Bifocal Co-payment of $25 Not subject to payment of the Annual Deductible. • Trifocal Co-payment of $25 Not subject to payment of the Annual Deductible. • Lenticular Co-payment of $25 Vision Care Service What Is the Frequency of Service? Network Benefit - The Amount You Pay Based on the Contracted Rate Not subject to payment of the Annual Deductible. Optional Lens Extras* *Coverage for some Optional Lens Extras, which may include progressive lenses, may be included with eyeglass packages offered at some Network locations. Once every 12 months. Standard Scratch Coating None Not subject to payment of the Annual Deductible. Eyeglass Frames Up to $130 Once every 12 months. None Not subject to payment of the Annual Deductible. Contact Lenses* *If Contact Lenses that are not on the Formulary are prescribed; the member will be responsible for the Contact Lens Fitting and Evaluation -Coverage for Covered Contact Lens Formulary will not apply at Walmart, Sam's Club, and Costco locations. Other Network locations may not offer Formulary contact lenses. In those cases, your allowance for Contact Lenses that are not on the Formulary will apply. Once every 12 months. Contact Lenses Formulary Up to 4 boxes (In lieu of glasses) Includes Fitting and Evaluation Co-payment of $25 Not subject to payment of the Annual Deductible. Contact Lenses Non-Formulary (In lieu of glasses) Up to $105 allowance None Not subject to payment of the Annual Deductible. Policy Table of Contents Section 1: Covered Health Care Services 9 Section 2: Exclusions and Limitations 29 Section 3: When Coverage Begins and Premiums 32 Section 4: When Coverage Ends 40 Section 5: How to File a Claim 43 Section 6: Questions, Complaints and Appeals 45 Section 7: General Legal Provisions 53 Section 8: Defined Terms 59 Section 9: Coordination of Benefits 74 Section 10: Outpatient Prescription Drugs 79 Section 11: Pediatric Dental Care Services 88 Section 12: Pediatric Vision Care Services 93 Section 13: Adult Dental Care Services 98 Section 14: Adult Vision Care Services 103 Amendment: Off-Exchange Qualified Health Plan 106 Section 1: Covered Health Care Services‌ When Are Benefits Available for Covered Health Care Services? Benefits are available only when all of the following are true: • The health care service, including supplies or Pharmaceutical Products, is only a Covered Health Care Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered Health Care Service in Section 8: Defined Terms.) • You receive Covered Health Care Services while this Policy is in effect. • You receive Covered Health Care Services prior to the date that any of initial evaluation. If the individual termination conditions listed in Section 4: When Coverage Ends occurs. • The person who receives Covered Health Care Services required Authorization is a Covered Person and meets all eligibility requirements. The fact that a Physician or other provider has performed or prescribed a procedure or treatmentnot obtained, or the fact that it may entire charge for such services will be the only available treatment for Member’s responsibility. Surgery must be performed within the time frame from the preoperative examination stated in the Schedule of Vision Benefits. If a Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms Member does not mean obtain the surgery within this time period and another pre-operative examination is necessary, the cost of that the procedure or treatment is a Covered Health Care Service examination will not be covered under this PolicyBenefit Plan. This section describes Covered Health Care Services If according to the Schedule of Vision Benefits the Member’s plan does not cover Laser Vision Correction Services, Members could have a discount for which Benefits are availablesuch services through Xxxxx Vision. Please refer to the attached Schedule of Benefits ask Xxxxx Vision for details about: • The amount you must pay for these Covered Health Care Services (including any Annual Deductible, Co- payment and/or Co-insurance)details. • Any limit that applies to these Covered Health Care Services (including visit, day and dollar limits on services). • Any limit that applies to the portion of the Allowed Amount or the Recognized Amount when applicable, you are required to pay in a year (Out-of-Pocket Limit). • Any responsibility you have for obtaining prior authorization or notifying us. Please note that in listing services or examples, when we say "this includes," it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list "is limited to."B.