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

000849845 55-1092 (1/22) ® Registered Marks of the Blue Cross and Blue Shield Association. ® ́ Registered Marks and SM Service Marks are property of their respective owners. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711 ). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711 ). Benefits you can see—from a company you trust Call customer service at 1-855-875-6948 . To locate an in-network provider, visit blue2020ma.com .* *Registration not required to search for providers. Questions? FAVORITE NATIONAL RETAILERS and many regional retailers. ONLINE SHOPPING OPTIONS • Glasses.com • Contactsdirect.com • Ray-Ban.com • Targetoptical.com • Lenscrafters.com Piggy-bank Special Offers for additional savings Find them at blue2020ma.com . SAVE ON HEARING EXAMS AND HEARING AIDS Offered by Amplifon Hearing, an independent company. To learn more about the savings available, visit amplifonusa.com/blue2020 . To get started, call 1-866-921-5367 . Chart-network Eye Trophy ACCESS TO ONE OF THE NATION’S LARGEST VISION NETWORKS THOUSANDS OF INDEPENDENT PROVIDERS AWARD-WINNING CUSTOMER SERVICE SM ® ́ ® ́