BCBS Vision Benefits Summary

For costs and further details about the coverage, including exclusions, refer to your member booklet. 1. Your actual expenses for covered services may exceed the stated out-of-network amount. 2. Indicates a service that is a discounted arrangement as part of your vision plan. 3. Consult with your eye care provider. 4. Discount applies to materials only and not to fittings for contact lenses. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. 40% OFF A COMPLETE SECOND PAIR OF GLASSES 20% OFF NON-PRESCRIPTION SUNGLASSES 15% OFF RETAIL PRICE OR 5% OFF PROMOTIONAL PRICE FOR LASER VISION CORRECTION THROUGH U.S. LASER NETWORK Additional in-network savings and discounts BLUE 20/20 Exam-PLUS Vision Plan: Insight Network $150 - 12/12/24 Frequency Blue 20/20 is administered by EyeMed Vision Care® ́, an independent company. Vision care service In-network member cost Out-of-network reimbursement 1 Comprehensive eye exam $10 copay up to $50 Contact lens fit and follow-up 2 • Standard • Premium up to $40 10% off retail price n/a n/a Retinal imaging up to $39 n/a Enhanced Diabetes Eye Care Benefit 3 For members diagnosed with type 1 or type 2 diabetes Paid in full: up to two diabetic eye exams and diagnostic testing every 12 months n/a Frames $150 allowance, then additional 20% off the balance up to $90 Standard plastic lenses • Single vision • Bifocal • Trifocal • Lenticular • Standard progressive lens • Premium progressive lens Tier 1–Tier 3 Tier 4 $25 copay $25 copay $25 copay $25 copay $90 copay $110–$135 copay $90 copay, then 80% of charge less $120 allowance up to $42 up to $78 up to $130 up to $130 up to $140 up to $196 up to $196 Lens options 2 • UV treatment • Tint (solid and gradient) • Standard plastic scratch coating • Standard polycarbonate • Standard polycarbonate for covered dependents under age 19 • Standard anti-reflective coating • Premium anti-reflective coating Tier 1–Tier 2 • Photochromic/Transitions® ́ plastic • Polarized • Other add-ons $15 $15 $15 $40 Paid in full $45 $57 - $68 $75 20% off retail price 20% off retail price n/a n/a n/a n/a up to $26 n/a n/a n/a n/a n/a Contact lenses 4 • Conventional • Disposable • Medically necessary $150 allowance, then additional 15% off the balance $150 allowance Paid in full up to $120 up to $120 up to $210 Frequency • Exam • Lenses for frames or one order of contact lenses • Frames once every 12 months once every 12 months once every 24 months