Balanced Care VisionSM. Choice Vision Insurance that Helps Employers Balance Features and Cost

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1 Balanced Care VisionSM Choice Vision Insurance that Helps Employers Balance Features and Cost Standard Insurance Company The Standard Life Insurance Company of New York Standard Insurance Company is licensed to issue insurance in all states except New York. The Standard Life Insurance Company of New York is licensed to issue insurance in only the state of New York.

2 The Value Is Clear 2 The Standard

3 Growing screen time and an aging workforce are just two reasons Vision insurance has become a vital benefit. This coverage can encourage your employees to seek preventive care to stay healthy and productive. Added to a competitive benefits package, Vision insurance can also help your organization look better to job candidates. Find the Right Balance with Our Vision Plans The Standard offers three Vision plans to help employers balance features and cost while meeting the diverse needs of their employees. All three plans provide benefits for groups as small as 10 enrolled employees. As always, all three plans are backed by our commitment to excellent customer service. Balanced Care Vision SM Plan I The VSP Vision Care Choice nationwide network of doctors is the basis for this plan.* It provides employees with network discounts and a large doctor directory. Balanced Care Vision SM Plan II This plan offers members the convenience of the EyeMed Vision Care Access nationwide network, which includes some of the largest optical retailers in the U.S., including LensCrafters, Sears Optical, Target Optical, JCPenney Optical and most Pearle Vision SM locations. Balanced Care Vision SM Plan III Our most flexible plan offers a simple schedule of benefits for claims, ensuring that employees know precisely how much is covered before receiving services. The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by Standard Insurance Company of Portland, Oregon, in all states except New York, where insurance products are offered by The Standard Life Insurance Company of New York of White Plains, New York. * VSP is a registered trademark of Vision Service Plan. Balanced Care Vision SM Choice 3

4 Balanced Care Vision SM Plan I Benefits VSP Choice Doctor Out-of-Network Annual Eye Exam 100% covered Covers up to $45 Single Vision Lenses 100% covered Covers up to $30 Bifocal Lenses 100% covered Covers up to $50 Trifocal Lenses 100% covered Covers up to $65 Frames Covers up to $130 Covers up to $70 Elective Contact Lenses Covers up to $130 Covers up to $105 Medically Necessary Contact Lenses 100% covered Covers up to $210 Other Benefits with a VSP Doctor Enjoy 20 percent off additional non-covered complete pairs of prescription glasses and sunglasses Contact lens exam, fitting and follow-up have a maximum member cost of $60 Get special pricing on lens options such as ultraviolet coating, progressive lenses, etc. For LASIK or Photorefractive Keratectomy (PRK), save an average of 15 percent off the usual and customary price or 5 percent off the promotional price with VSP and a contracted laser surgery center Find a VSP doctor at or call VSP at Plan Specifics VSP provides up to $130 toward new frames. Members receive a 20 percent discount off the excess amount for frames that exceed the allowance Members pay a $10 annual deductible on exams and $25 annual deductible on materials Frequency for Exam/Lenses/Frames is 12/12/24 months With the 12/12/24 frequency: contacts are in lieu of eyeglasses; normal frequency rules apply (selecting contacts does not reset the frames frequency, as contacts and frames frequencies work independently) Monthly Rates Contributory or Voluntary Non-contributory Employee $8.48 $6.96 Employee + Spouse 1 $18.28 $14.96 Employee + Child(ren) 2 $14.76 $12.12 Family $24.56 $20.12 Plan V The Standard

5 Balanced Care Vision SM Plan II Benefits EyeMed Access Network Out-of-Network Annual Eye Exam 100% covered Covers up to $35 Single Vision Lenses 100% covered Covers up to $25 Bifocal Lenses 100% covered Covers up to $40 Trifocal Lenses 100% covered Covers up to $55 Frames Covers up to $110 Covers up to $45 Elective Contact Lenses Covers up to $115 Covers up to $100 Medically Necessary Contact Lenses 100% covered Covers up to $200 Plan Specifics EyeMed Vision Care provides up to $110 toward new frames. If the member exceeds this allowance, they will receive a 20 percent discount off the excess amount Members pay a $10 annual deductible on exams and $25 annual deductible on eyeglass lenses Frequency for Exam/Lenses/Frames is 12/12/24 months With the 12/12/24 frequency: contacts are in lieu of any other lens benefit; normal frequency rules apply (selecting contacts does not reset the frames frequency, as lens and frames frequencies work independently) Monthly Rates Contributory or Voluntary Non-contributory Employee $7.48 $5.96 Employee + Spouse 1 $16.12 $12.84 Employee + Child(ren) 2 $13.00 $10.36 Family $21.64 $17.24 Plan V00270 Rates have been extended for policy effective dates through 2/1/16. Vision rates are guaranteed for two years, or to align with Section 125 plan year. Rates are valid for groups up to 500 enrolled employees. 1 Spouse may include a civil union or domestic partnership. Eligibility not available in all states. Contact your sales representative at The Standard for details. 2 Child may include a child of a civil union or domestic partnership. Eligibility not available in all states. Contact your sales representative at The Standard for details. Other Benefits Get up to 40 percent off additional purchases of complete glasses Enjoy 20 percent off items not covered by the plan Get 15 percent off any remaining amount that exceeds the conventional contact lens allowance Contact lens exam, standard fit and follow-up have a maximum member cost of $55 premium fit and follow-up receive a 10 percent discount from retail Special pricing on lens options such as ultraviolet coating For LASIK and Photorefractive Keratectomy, save 15 percent off the retail price or 5 percent off the promotional price with U.S. Laser Network owned by LCA-Vision Find a provider at or call EyeMed at Balanced Care Vision SM Choice 5

6 Balanced Care Vision SM Plan III Benefits Annual Eye Exam Covers up to $50 Single Vision Lenses Covers up to $40 Bifocal Lenses Covers up to $60 Progressive Lenses Covers up to $80 Lenticular Lenses Covers up to $80 Trifocal Lenses Covers up to $75 Contact Lenses Covers up to $100 Frames Covers up to $80 In the Balanced Care Vision SM Plan III, covered benefits are the same no matter which provider you choose. Other Benefits Choose any vision care provider Employees pay for all services, then submit a claim to The Standard for reimbursement A schedule of benefits for claims ensures that your employees know precisely how much is covered before receiving services Plan Specifics The member will be responsible for any deductible, if applicable, and any cost over the specified plan benefits Plan includes a calendar year deductible of $20 for exam/materials Frequency for Exam/Lenses/Frames is 12/12/24 months With the 12/12/24 frequency: contacts are in lieu of eyeglasses; normal frequency rules apply (selecting contacts does not reset the frames frequency, as contacts and frames frequencies work independently) After the doctor is paid for services, the member may submit a claim within 90 days for reimbursement (180 days in North Carolina) Monthly Rates Contributory or Voluntary Non-contributory Employee $5.48 $3.96 Employee + Spouse 3 $11.80 $8.52 Employee + Child(ren) 4 $9.52 $6.88 Family $15.84 $11.44 Rates have been extended for policy effective dates through 2/1/16. Vision rates are guaranteed for two years, or to align with Section 125 plan year. Rates are valid for groups up to 500 enrolled employees. 3 Spouse may include a civil union or domestic partnership. Eligibility not available in all states. Contact your sales representative at The Standard for details. 4 Child may include a child of a civil union or domestic partnership. Eligibility not available in all states. Contact your sales representative at The Standard for details. 6 The Standard

7 Details for All Vision Plans Not all plans are available in all states. Please contact your local Employee Benefits Sales and Service office for information on plan availability in your state. Employer funding is not required. If no employer money is involved, it is assumed the Vision plan will be sold in conjunction with a bona fide cafeteria plan regulated by Section 125 of the Internal Revenue Code, and it must meet all Section 125 requirements. The rates and benefits quoted are based on a minimum of 10 enrolled employees. All rates and benefits quoted are not valid if the final enrollment is below the minimum threshold. No benefits are payable for a service that is not included in the list of eye care services found in the certificate Benefits are available for all full-time, active employees working at least 30 hours per week who have completed the designated eligibility waiting period This booklet highlights the Vision coverage available from The Standard. Please refer to the Certificate of Insurance for a complete list of covered procedures. Added to a competitive benefits package, Vision insurance can help your organization look better to job candidates. Balanced Care Vision SM Choice 7

8 Exclusions and Limitations Balanced Care Vision SM Plan I Covered Expenses will not include, and no benefits will be payable for, expenses incurred for: Eye exam more than once in any 12-month period Lenses more than once in any 12-month period Frames more than once in any 24-month period Elective contact lenses more than once in any 12-month period (contact lenses and associated expenses are in lieu of any other lens or frames benefit) Medically necessary contact lenses more than once in any 12-month period (the treating provider determines if the insured meets the coverage criteria for this benefit which is in lieu of elective contact lenses) Any procedure to change the shape of the cornea to reduce myopia Refitting of contact lenses after the initial 90-day fitting period Artistically painted contact lenses Lens insurance policies or service contracts Additional office visits associated with contact lens pathology Contact lens modification, polishing or cleaning Orthoptics or eye care training and any associated testing Standard Plano contact lenses or Plano contact lenses to change eye color Two pairs of glasses in lieu of bifocals Replacement of lenses and frames that are lost or broken outside of the normal coverage intervals Medical or surgical treatment of the eyes Claims filed more than 180 days after completion of service, unless the insured shows it was not possible to submit the proof of loss within this period The following materials, over and above the covered expense for the basic material: blended lenses oversize lenses photochromic, tinted lenses except pink #1 and #2 Coating or laminating of the lens or lenses Corrective vision treatments that are experimental Corneal Refractive Therapy (CRT) Costs for services and/or materials that exceed the maximum covered expense Services or materials that are cosmetic 8 The Standard

9 Balanced Care Vision SM Plan II Covered Expenses will not include, and no benefits will be payable for, expenses incurred for: Eye exam more than once in any 12-month period Ophthalmic lenses more than once in any 12-month period Frames more than once in any 24-month period Elective contact lenses more than once in any 12-month period (contact lenses and associated expenses are in lieu of any other lens benefit) Medically necessary contact lenses more than once in any 12-month period. For the insured to receive this benefit, it must be in lieu of elective contact lenses and be determined by the treating provider to meet the following coverage criteria: Keratoconus where the patient is not correctable to 20/30 in either or both eyes using standard spectacle lenses High Ametropia exceeding -10 D or +10 D in spherical equivalent Anisometropia of 3 D or more Patients whose vision can be corrected two lines of improvement on the visual acuity chart when compared to best standard spectacle lens correction Orthoptics or eye care training and any associated testing Plano lenses Non-prescribed lenses or sunglasses Two pairs of glasses in lieu of bifocals Replacement of lenses and frames that are lost or broken, outside of the normal coverage intervals Medical and/or surgical treatment of the eyes, or supporting structures Claims filed more than one year after completion of the service, unless the insured shows it was not possible to submit the proof of loss within this period Balanced Care Vision SM Choice 9

10 Balanced Care Vision SM Plan III Covered Expenses will not include, and no benefits will be payable for, expenses incurred for: Vision examinations more than once in any 12-month period Lenses more than once in any 12-month period Frames more than once in any 24-month period Contact lenses more than once in any 12-month period. When chosen during the 12-month period: contact lenses shall be in lieu of any other lens or frame benefit lenses and frames shall be in lieu of any contact lens expenses Examinations performed or frames or lenses ordered before the insured was covered under the eye care expense benefits Any examination performed or frame or lens ordered after the insured s coverage under the eye care expense benefits ceases (subject to extension of benefits) Sub-normal eye care aids; orthoptic or eye care training or any associated testing Non-prescription lenses Replacement or repair of lost or broken lenses or frames except at normal intervals Any eye examination or corrective eyewear required by an employer as a condition of employment Medical or surgical treatment of the eyes Any service or supply not shown on the Schedule of Eye Care Procedures Coated lenses; oversize lenses (exceeding 71 mm); photo-gray lenses; polished edges; UV-400 coating and facets; and tints other than solid Claims filed more than 90 days (180 days for North Carolina) after completion of the service, unless the insured shows it was not possible to submit the proof of loss within this period 10 The Standard

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12 Standard Insurance Company s first group policy, written in 1951 and still in force today, stands as a testament to our commitment to building long-term relationships. Founded in Portland, Oregon, in 1906, Standard Insurance Company is a nationally recognized provider of Group Disability, Life, Dental and Vision insurance. The Standard Life Insurance Company of New York, founded in White Plains, New York, in 2000, is the sister company of Standard Insurance Company. To learn more about group Vision insurance from The Standard, contact your insurance advisor, call the Employee Benefits Sales and Service Office for your area at or visit us at The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by Standard Insurance Company of 1100 SW Sixth Avenue, Portland, Oregon, in all states except New York, where insurance products are offered by The Standard Life Insurance Company of New York of 360 Hamilton Avenue, Suite 210, White Plains, New York. Product features and availability vary by state and company, and are solely the responsibility of each subsidiary. Each company is solely responsible for its own financial condition. Standard Insurance Company is licensed to solicit insurance business in all states except New York. The Standard Life Insurance Company of New York is licensed to solicit insurance business in only the state of New York. Standard Insurance Company The Standard Life Insurance Company of New York Balanced Care Vision SM Choice (1/15) SI/SNY PR/ER