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CITY OF SUNNY ISLES BEACH Benefit presented is for 03/01/2009 effective date. Member Copay: Exam Lens Frequency: Exam Frame Lenses or Contacts $10.00 $10.00 Once per 12 mths Once per 24 mths Once per 12 mths Monthly Fee: Subscriber Only Subscriber + Spouse Subscriber + Child[ren] Subscriber + Family $5.68 $10.76 $11.32 $16.68 Rate Contribution Level Definition: Non-Voluntary (Employer pays greater than 80% or bundled with Medical/Dental) Rate Terms and Conditions: Benefit presented has a 24-month policy term and rate guarantee. Pricing includes broker commissions. Rates are valid based on group domiciled in the state of FL and group size of 10 - 500 eligible employees. Fees quoted are valid until the stated effective date. www.eyemedvisioncare.com Plan Limitations / Exclusions: Select Exam & Materials - Medium Option BENEFIT DESIGN SUMMARY EyeMed Vision Care in conjunction with Fidelity Security Life Insurance Company Vision Care Services In-Network Out-of-Network Exam with Dilation as Necessary: Member Cost $10 Copay Up to $35 Member Reimbursement Contact Lens Fit and Follow Up(Contact lens fit and two follow-up visits are available after comprehensive eye exam): Standard' Premium' Up to $40 10% off Retail N/A N/A $48 Frames(any available frame at provider location): Standard Plastic Lenses: Single Vision Bifocal Trifocal Standard Progressive Lens' Premium Progressive Lens' $0 Copay; $120 Allowance, 20% off balance over $120 $10 Co pay $10 Co pay $10 Copay $10,80% of charge less $55 allowance $10,80% of charge less $55 allowance Up to $25 Up to $40 Up to $60 Up to $40 Up to $40 Lens Options(paid by the member): UV Treatment Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate Standard Anti-reflective Coating Other Add-Ons and Services 20% off retail price 20% off retail price 20% off retail price 20% off retail price 20% off retail price 20% off retail price N/A N/A N/A N/A N/A N/A Contact LenSeS:(allowance includes materials only) Conventional $135 allowance, 15% off balance over $135 Disposable $135 allowance, plus balance over $135 Medically Necessary $0 Copay, Paid-in-Full $95 $95 $200 1 Standard Contact Lens Fitting. spherical clear contact lenses in conventional wear and planned replacement (examples include but not limited to dIsposable, frequent replacement, etc.) 2 Premium Contact Lens Fitting. all lens designs, materials and specialty fittings other than Standard Contact Lenses (examples include torie, multifocal, etc.) 3 Standard/Premium Progressive Lens not covered - fund as a Bifocal Lens Standard Progressive Lens covered - fund Premium Progressive as a Standard Additional Value Added Savings Members will receive a 20% discount on items not covered by the plan at network Providers, which may not be combined with any other discounts or promotional offers, and the discount does not apply to EyeMed Provider's professional services, or contact lenses. Retail prices may vary by location. Discounts do not apply for benefits provided by other group benefit plans. Allowances are one-time use benefits; no remaining balance. Lost or broken matenals are not covered. Members also receive a 40% discount off complete pair eyeglass purchases and a 15% discount off conventional contact lenses once the funded benefit has been used. Members also receive 15% off retail pnce or 5% off promotional price for Lasik or PRK from the US Laser Network, owned and operated by LeA Vision. Since Lasik or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available from a provider in your immediate location. For a location near you and the discount authorization please call 1-877- 5LASER6. After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member. Details are available at www.eyemedvisioncare.com. The contact lens benefit allowance is not applicable to this service. This plan design is offered with the EyeMed Select panel of providers. Minimum 10 enrolled employees required. Underwriter Insured plans are underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, except in New York. Fidelity Security Life Policy number VC-73 andVC-74, form number M-9059. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer. . Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing Services provided as a result of any Workers Compensation law Aniseikonic lenses Services or materials provided by any other group benefit providing for vision care Certain frame brands in which the manufacturer imposes a no discount policy Corrective eyewear required by an employer as a condition of employment, and safety eyewear unless specifically covered under plan Medical and/or surgical treatment of the eye, eyes, or supporting structures Two pair of glasses in lieu of bifocals PIano lenses and non-prescription sunglasses (except for 20% discount) Some provisions, benefits, exclusions or limitations listed herein may vary by State If CITY OF SUNNY ISLES BEACH has chosen this benefit and agrees to the administrative services and requirements outlined above. please sign below and return this sheet with your completed application to your EyeMed sales representative. CA Signature