Balanced Care VisionSM. Choice. Options to Help Your Employees Stay Focused at Work

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1 Balanced Care VisionSM Choice Options to Help Your Employees Stay Focused at Work 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 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 providers is the basis for this plan.* It provides employees with network discounts and a large provider directory. Balanced Care Vision SM Plan II This plan offers members the convenience of the EyeMed SM Vision Care Insight 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. 2 The Standard

3 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 Allowances Covers up to $120, $130, $150 or $180 Elective Contact Lenses (ECL) Allowances Medically Necessary Contact Lenses (as determined by physician) Plan I Specifics VSP provides a 20 percent discount off excess amount for frames over $110. Allowances for Frames and ECL must match. Allowances for out-of-network Frames and ECL corresponds to chosen in-network allowance option. Members pay a $10 annual deductible on exams and $25 annual deductible on materials. Covers up to $120, $130, $150 or $180 Covers up to $70 Covers up to $ % covered Covers up to $210 Members also receive access to affiliates such as Visionworks and Costco Optical retail chains. Frequency for exam/lenses/frames is 12/12/24 months. Contacts are in lieu of eyeglasses, frames and lenses in any 12-month period. Prescription safety glasses may be selected in lieu of eyeglasses. Additional Benefits with a VSP Provider 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 provider at or call VSP at Plan I Monthly Rates Frame/CL Allowances $120/$120 $130/$130 $150/$150 $180/$180 4-Tiered Employee $8.40 $6.92 $8.68 $7.12 $9.00 $7.36 $9.56 $7.84 Employee + Spouse 1 $18.16 $14.88 $18.72 $15.32 $19.40 $15.88 $20.60 $16.84 Employee + Child(ren) 2 $14.68 $12.08 $15.12 $12.44 $15.68 $12.88 $16.64 $13.68 Family $24.40 $20.04 $25.16 $20.64 $26.08 $21.40 $27.68 $ Tiered Employee $8.40 $6.92 $8.68 $7.12 $9.00 $7.36 $9.56 $7.84 Employee + 1 Dependent $16.52 $12.72 $17.04 $13.12 $17.64 $13.60 $18.76 $14.44 Employee + 2 Dependents $23.92 $19.60 $24.68 $20.20 $25.56 $20.92 $27.16 $22.24 V20014 V20001 V20021 V20048 Rates have been extended for policy effective dates through Feb. 1, Vision rates are guaranteed for four 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. 2 Child may include a child of a civil union or domestic partnership. Eligibility not available in all states. Balanced Care Vision SM Choice 3

4 Additional 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 $40 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 ** All discounts subject to state approval Balanced Care Vision SM Plan II Benefits EyeMed Insight 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 Allowances Covers up to $115, $130, $150 or $180 Elective Contact Lenses (ECL) Allowances Medically Necessary Contact Lenses (as determined by physician) Plan II Specifics EyeMed Vision Care provides a 20 percent discount off excess amount for frames over $110. Combinations for Frames and ECL are shown below. Allowances for out-of-network Frames and ECL corresponds to chosen in-network allowance option. Covers up to $110, $130, $150 or $180 Covers up to $65 Covers up to $ % covered Covers up to $200 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. Contacts and frames may both be selected in the same 12-month period. Plan II Monthly Rates Frame/CL Allowance $110/$115 $130/$130 $150/$150 $180/$180 4-Tiered Rates have been extended for policy effective dates through Feb. 1, Vision rates are guaranteed for four 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. 4 Child may include a child of a civil union or domestic partnership. Eligibility not available in all states. Employee $7.32 $5.84 $7.96 $6.36 $8.64 $6.88 $9.52 $7.60 Employee + Spouse 1 $15.80 $12.60 $17.24 $13.72 $18.64 $14.88 $20.56 $16.40 Employee + Child(ren) 2 $12.76 $10.16 $13.92 $11.08 $15.04 $12.00 $16.60 $13.20 Family $21.20 $16.88 $23.12 $18.40 $25.00 $19.92 $27.56 $ Tiered Employee $7.32 $5.84 $7.96 $6.36 $8.64 $6.88 $9.52 $7.60 Employee + 1 Dependent $13.52 $10.80 $14.72 $11.76 $15.96 $12.76 $17.56 $14.04 Employee + 2 Dependents $20.80 $16.60 $22.68 $18.08 $24.56 $19.60 $27.04 $21.60 V01007 V01013 V01019 V The Standard

5 Balanced Care Vision SM Plan III Benefit Allowances - Flat Max ($150) is available as an option to allowances shown below Annual Eye Exam Covers up to $50 Single Vision Lenses Covers up to $40 Bifocal Lenses Covers up to $60 Trifocal Lenses Covers up to $75 Progressive Lenses Covers up to $80 Contact Lenses Covers up to $100 Frames Covers up to $80 In the Balanced Care Vision Plan III, covered benefits are the same no matter which provider you choose. Plan III Specifics Frequency for exam/lenses/frames is 12/12/24 months. Contacts are in lieu of eyeglasses, frames and lenses in any 12-month period. Plan III Monthly Rates 4-Tiered Schedule After the provider is paid for services, the member may submit a claim within 90 days for reimbursement (180 days in North Carolina). Flat Max Employee $5.76 $4.16 $7.48 $5.40 Employee + Spouse 5 $12.40 $8.96 $15.96 $11.52 Employee + Child(ren) 6 $10.00 $7.24 $13.48 $9.76 Family $17.68 $12.00 $24.44 $ Tiered Employee $5.76 $4.16 $7.48 $5.40 Employee + 1 Dependent $10.60 $7.64 $14.64 $10.56 Employee + 2 Dependents $16.28 $11.76 $28.76 $20.76 Additional Benefits Freedom to choose any visioncare 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. All rates have been extended for policy effective dates through Feb. 1, Vision rates are guaranteed for four years, or to align with Section 125 plan year. Rates are valid for groups up to 500 enrolled employees. Please check for availability in your state. Based on applicable laws, reduced costs may vary by provider locations. 5 Spouse may include a civil union or domestic partnership. Eligibility not available in all states. 6 Child may include a child of a civil union or domestic partnership. Eligibility not available in all states. Balanced Care Vision SM Choice 5

6 Details for All Vision Plans This brochure highlights the Vision coverage available through The Standard. Please refer to the Certificate of Insurance for a complete list of covered procedures. Plans and options listed are available in most, but not all, states. Contact your local employee benefits sales and service office for information on plan availability. 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 eyecare 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. COBRA administration costs are $0.63 per covered employee. 6 The Standard

7 Exclusions and Limitations Covered Expenses will not include, and no benefits will be payable for, expenses incurred for: Balanced Care Vision SM Plans I, II, III Orthoptics or eyecare training and any associated testing Replacement of lenses and frames that are lost or broken outside of the normal coverage intervals Medical and/or surgical treatment of the eyes Claims filed more than [Plan I 180 days, Plan II one year, Plan III 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 Balanced Care Vision SM Plan I 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) Refitting of contact lenses after the initial 90-day fitting period Contact lens insurance policies or service contracts Additional office visits associated with contact lens pathology Contact lens modification, polishing or cleaning Two pairs of glasses in lieu of bifocals Plano lenses (lenses with refractive correction of less than plus or minus.50 diopter) except as specifically allowed in the frames benefit section of the Plan Benefits Coating or laminating of the lens or lenses Services or materials that are cosmetic, including plano contact lenses to change eye color and artistically painted contact lenses Local, state and/or federal taxes, except in cases that The Standard is required by law to pay Membership fees for any retail center in which an affiliate or open access provider office may be located; covered persons may be required to purchase a membership in such entities to access plan benefits Balanced Care Vision SM Plan II 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) Plano lenses (lenses with refractive correction of less than plus or minus.50 diopter) except as specifically allowed in the frames benefit section of the Plan Benefits Non-prescribed lenses or sunglasses Two pairs of glasses in lieu of bifocals Balanced Care Vision SM Plan III Examinations performed or frames or lenses ordered before or after the insured was covered under the eye care expense benefits Sub-normal eye care aids Non-prescription lenses Any eye examination or corrective eyewear required by an employer as a condition of employment 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 Balanced Care Vision SM Choice 7

8 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. This policy provides VISION insurance only. Standard Insurance Company The Standard Life Insurance Company of New York Balanced Care Vision SM Choice (12/17) SI/SNY PR/ER