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Benets Member Coverage Out o Network Reimbursement

Eye Examination

Copay

Frequency

$10

12 months

Up to a $30 allowance

12 months

Spectacle Lenses

Copay1

Frequency

All ranges, prescriptions andsizes including glass or plastic

Additional Options: Polycarbonate lensesFashion and gradient tinting o plastic lensesGlass-grey #3 prescription sunglassesScratch resistant coating

$20

12 months

Included

$0 children/$35 copay adults$15 copay$15 copay$20 copay

Per pair:

Single vision up to a $25 allowance

Biocal up to a $35 allowance

Triocal up to a $45 allowanceLenticular up to a $60 allowance

Frame

In-network retail allowance

Frequency

Exclusive collections o rames:(in lieu of frame allowance)

Fashion (up to $100 retail value)

Designer (up to $175 retail value)Premier (up to $225 retail value)

$110 plus a Davis Vision network20% discount o overage

24 months

Included

$15 copay$40 copay

Up to a $30 allowance

24 months

Contact Lenses (in lieu o eyglasses)

Copay

Frequency

Elective allowance

Medically necessary (with prior approval)

$0

12 months

$110 plus a Davis Vision network15% discount o overage

Included

Up to a $75 allowance

12 months

Up to a $225 allowance

Value Added Features

One-year breakage warranty

Lens 1-2-3! membershipLaser Vision correction discount -up to 25% o the provider's U&Cor 5% o promo price

Included

IncludedIncluded

N/A

Denali One Lie Vision

Denali Vision utilizes the outstanding quality, value and service o Davis Vision. Davis Vision has been providing vision careservices or more than 42 years and currently serves more than 55 million people. The Davis Vision network consists onearly 30,000 providers throughout the country.

Additional lens options (copay) :

Standard progressives $65 Ultraviolet coating $15 Standard anti-refective coating $40 Photochromic glass lenses $2

Premium progressives $105 High-index lenses $60 Premium anti-refective coating $55 Plastic photosensitive lenses $7

Blended segment lenses $20 Polarized lenses $75 Ultra anti-refective coating $69 Intermediate vision lenses $3

*Additional discounts are not insurance benefts and are not available at participating Walmart or Sam's Club locations.1 One copay applies or rame and lenses when purchased together.

I rame and/or lenses are purchased separately, copays would apply toward rame & lenses. DB 1-Life Vision Region1 03

Optional vision insurance coverage available when Denali dental insurance is purchased

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Easy online accessThrough the Davis Vision website, employees have access to online features such as:

Finding the nearest provider in the areaDownloading claim ormsViewing beneitsViewing exclusive rame optionsChecking employee eligibility

Value-added benefits*One-year breakage warrantyAll plan eyeglasses come with a breakage warranty or repair or replacement o the rame and/or lenses or a period o one

year rom the date o delivery. The one-year breakage warranty applies to in-network eyeglasses covered by the plan (specta

lenses and Davis Vision Collection rames, or a national retailers rames where the Davis Vision Collection is not displayed).Replacement contact lens programDavis Visions proprietary Lens 1-2-3! mail order program oers the guaranteed lowest prices on contact lens replacements.Members can simply call 1-800-LENS-123 or visit www.lens123.com with their current prescription.

Laser vision correction discountsDavis Vision members are entitled to savings o up to 25 percent o the providers usual and customary ees, or a 5 percentdiscount on any advertised special through a network o physicians ailiated with Eye Centers o Excellence (some centersprovide a lat ee equating to these discount levels).

Davis Visions network is a blended network with a choice o all practice types including ophthalmologists, optometrists andmany o the nations premier retail centers. A large percentage o private practice providers also work in a retail/storerontenvironment. The ollowing are some o the national and regional retailers that are typically included in a Davis Vision progra

Davis Vision, Empire Vision Centers, Total Vision Care, Cambridge Eye Doctors, Douglas Vision World, Binyons Eye World,Dr. Bizers VisionWorld, Dr. Bizers ValuVision, Doctors ValuVision, Doctors Visionworks, Visionworks Eye DRx, EyeMastersHour Eyes, Sams Club, Stein Optical, VisionWorld, Walmart Vision Center

For a ull list o providers in your area, access our provider directory at www.davisvision.com, select Members and enterclient code 3096.

* The value-added beneits are available through Davis Vision and are not part o the insurance policy.

Denali Vision Rates

Monthly

Single $8.29

Single + 1 $14.51

Family $21.55

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Exclusions and limitationsBeneits will not be paid or and the term Covered Charges will not include the ollowing: Forservicesorsuppliesnotrecommendedbyaprovider. Forperiodicvisionexaminations,exceptasprovidedforintheScheduleofBenefits. Foreyeexaminationsrequiredbyanemployerasaconditionofemployment. Forservicesormaterialsprovidedinconnectionwithspecialproceduressuchasorthopticsandvisualtraining,orin

connection with medical or surgical treatment. Forlenseswhichdonotprovidevisioncorrection. Forchargesforthereplacementoflostorstolenlensesorframeswithin24monthsofservice.

ForsicknessorinjurycoveredbyaWorkersCompensationActorothersimilarlegislation. Incurredasadirectorindirectresultofwar(declaredorundeclared). Incurredasaresultofanintentionallyself-inflictedinjuryorinjurysustainedwhilecommittingacrime. ForservicesorsuppliesfurnishedtoaCoveredPersonbeforetheeffectivedateofaCoveredPersonsInsuranceunder

the Group Policy or ater the date a Covered Persons Insurance ends. ForservicesorsupplieswhicharenotgenerallyacceptedintheUnitedStatesasbeingnecessaryandappropriatefor thetreatmentofapatientssicknessorinjury. ForanymedicaltreatmentrenderedoutsidetheUnitedStates. Forservicesrenderedbypractitionerswhodonotmeetthedefinitionofprovider. Forexpensescoveredby:

a. Any other group insurance except as provided in Section 7 (except or Coordination o Beneits rules)b. A health maintenance organization or hospital or medical services prepayment plan available through an

employer, union or association. Foranyexpensescoveredbyanyunionwelfareplanorgovernmentalprogramoraplanrequiredbylaw. Forcomprehensivelowvisionevaluations,subsequentfollow-upvisitsfollowingsuchevaluationorlowvisionaidsfor

which prior approval was not obtained rom us or our authorized administrator. Formedicallynecessarycontactlensesprescribedforacoveredpersonaffectedwithkeratoconusforwhichprior

approval was not obtained rom us or our authorized administrator.

Important informationThis Denali Vision brochure is intended as a summary outline o the eatures, plan provisions, beneits, exclusions, limitationand other inormation about the group association vision insurance policies, issued to Communicating or America, thegroup policyholder, and underwritten by Madison National Lie Insurance Company, Inc. (group vision policy orm MNLGAVIS-POL 1107) and, in New Hampshire and New York, Standard Security Lie Insurance Company o New York (groupvision policy orm SSL GAVIS-POL 1107). Policy provisions and availability may vary by state and by insurance company.

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