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ahFrequency Exam once every plan year Frame once every plan year Lens once every plan year Contact Lens once every plan year (Plan allows member to receive either contacts and frame, or frames and lens services )40 %OFF additional complete pair of prescription eyeglasses 20 %OFF non-covered items, including non- prescription sunglasses SCHEDULE OF BENEFITSVISION CARE SERVICES IN-NETWORK MEMBER COST OUT-OF-NETWORK MEMBER REIMBURSEMENT Log into eyemed.com/member to see all plans included with your benefits. EyeMed reserves the right to make changes to the products available on each tier. All providers are not required to carry all brands on all tiers. For current listing of brands by tier, call 866-939-3633. No benefits will be paid for services or materials connected with or charges arising from: medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures; Refraction, when not provided as part of a Comprehensive Eye Examination; services provided as a result of any Workers' Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; any Vision Examination or any corrective Vision Materials required by a Policyholder as a condition of employment; safety eyewear; solutions, cleaning products or frame cases; non-prescription sunglasses plano (non-prescription) lenses; plano (non-prescription) contact lenses; two pair of glasses in lieu of bifocals; electronic vision devices; services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; or lost or broken lenses, frames, glasses, or contact lenses that are replaced before the next Benefit Frequency when Vision Materials would next become available. Fees charged by a Provider for services other than a covered benefit and any local, state or Federal taxes must be paid in full by the Insured Person to the Provider. Such fees, taxes or materials are not covered under the Policy. Some provisions, benefits, exclusions or limitations listed herein may vary by state. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see online provider locator to determine which participating providers have agreed to the discounted rate. Underwritten by Fidelity Security Life Insurance Company® of Kansas City, Missouri, except in New York. Fidelity Security Life Policy number VC-146, form number M-9184. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.City of Waterbury Insight networkFRAME Frame at PLUS Provider 20% off balance over $230 allowance Up to $126 Frame 20% off balance over $180 allowance Up to $126 STANDARD PLASTIC LENSES Single Vision $0 copay Up to $30 Bifocal $0 copay Up to $50 Trifocal/Lenticular $0 copay Up to $70 Progressive - Standard $0 copay Up to $50 Progressive - Premium Tier 1 - 4 $85 - 175 Up to $50 LENS OPTIONS Anti Reflective Coating - Standard $45 copay Up to $23 Anti Reflective Coating - Premium Tier 1 - 3 $57 - 85 Up to $23 Photochromic - Non-Glass $75 Not covered Polycarbonate - Standard $40 Not covered Polycarbonate - Std < 19 years of age $0 copay Up to $20 Scratch Coating $15 Not covered Tint $0 copay Up to $8 UV Treatment $15 Not covered All Other Lens Options 20% off retail price Not covered CONTACT LENSESContacts - Conventional 85% of balance over $180 allowance Up to $165 Contacts - Disposable 100% of balance over $180 allowance Up to $165 Contacts - Medically Necessary $0 copay; paid-in-full Up to $300 OTHERHearing Care from Amplifon Network Discounts on hearing aids; call 1.877.203.0675 Not covered Lasik or PRK from U.S. Laser Network 15% off retail or 5% off promo price; call 1.800.988.4221 Not covered EXAM SERVICES Exam at PLUS Providers $0 copay Up to $40 Exam $0 copay Up to $40 Retinal Imaging Up to $39 Not covered CONTACT LENS FIT AND FOLLOW-UP Fit and Follow-up - Standard Up to $40; contact lens fit and two follow-up visits Not covered Fit and Follow-up - Premium 10% off retail price Not covered

Savings plus convenience plus choice PLUS Providers add another layer of coverage Staying in-network helps you save money on eye exams, frames and lenses. Visiting a PLUS Provider is designed to help you save even more. And since PLUS Providers are already in our network, the additional perks are built right into your vision benefits. No promo codes, no coupons, no paperwork. The same vision benefits, plus a little more savings. The choice is yours Find plenty of in-network eye doctors — including PLUS Providers — on our Provider Locator. Just look for the PLUS. Need extra assistance? Contact us at 1.866.939.3633 or visit eyemed.com .avwx t u