Common use of Out of Network Clause in Contracts

Out of Network. Examination – once a calendar year Covered 100% (after $6.50 co-pay) Optometrist reimbursed up to $28.50 Ophthalmologist reimbursed up to $38.50 Frames – once a calendar year Up to $65 retail Reimbursed up to $44 Lens – once a calendar year Single Bi-focal Tri-focal Lenticular Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Clear/color tints & coats/ polarized $29/$33/$47 reimbursement $51/$61/$81 reimbursement $63/$75/$101 reimbursement $75/$89/$119 reimbursement Contact Lens (in lieu of lens/frame) – once a calendar year Elective Medically necessary (prior authorization is required) Up to $90 Covered 100% Reimbursed up to $90 Reimbursed up to $175

Out of Network. Examination – once a calendar year Covered 100% (after $6.50 co-pay) Optometrist reimbursed up to $28.50 Ophthalmologist reimbursed up to $38.50 Frames – once a calendar year Up to $65 retail Reimbursed up to $44 Lens – once a calendar year Single Bi-focal Tri-focal Lenticular Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Clear/color tints & coats/ polarized $29/$33/$47 reimbursement $51/$61/$81 reimbursement $63/$75/$101 reimbursement $75/$89/$119 reimbursement Contact Lens (in lieu of lens/frame) – once a calendar year Elective Medically necessary (prior authorization is required) ): Up to $90 Covered 100% Reimbursed up to $90 Reimbursed up to $175

Out of Network. Examination – once a calendar year Covered 100% (after $6.50 co-pay) Optometrist reimbursed up to $28.50 Ophthalmologist reimbursed up to $38.50 Frames – once a calendar year Up to $65 retail Reimbursed up to $44 Lens – once a calendar year Single Bi-focal Tri-focal Lenticular Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Clear/color tints & coats/ polarized $29/$33/$47 reimbursement $51/$61/$81 reimbursement $63/$75/$101 reimbursement $75/$89/$119 reimbursement Contact Lens (in lieu of lens/frame) – once a calendar year Elective Medically necessary (prior Prior authorization is required) ): Up to $90 Covered 100% Reimbursed up to $90 Reimbursed up to $175