Vision Care Plan Member options price list — effective April 28, 2014 Options Nonaspheric styles* Standard plastic Mid-index 1.53–1.59 High-index 1.60–1.66 High-index 1.67–1.70 High-index 1.71–1.74 † Trivex®/Trilogy®/TREXA™ † Phoenix Polycarbonate (age 19 and higher) Polycarbonate (under age 19) † Glass 1.523 standard High-index glass Aspheric styles ** Standard plastic Polycarbonate Mid-index 1.53–1.59 High-index 1.60–1.66 High-index 1.67–1.70 High-index 1.71–1.74 † Trivex/Trilogy/TREXA † Phoenix Polarized styles Polarized plastic Polarized mid-/high-index Polarized polycarbonate Polarized glass † Xperio UV® (Crizal backside AR is automatically included) Charged in addition to appropriate material † Xperio UV Mirrors (Crizal backside AR is automatically included) Charged in addition to appropriate material Specialty lenses † Crizal Kids UV™ Polycarbonate (Crizal AR is automatically included) Essilor 360 SV™ Aspheric Polycarbonate High-index 1.67 High-index 1.74 Essilor Azio SV™ Aspheric Polycarbonate High-index 1.67 High-index 1.74 Essilor eyecode™ SV Aspheric Polycarbonate High-index 1.67 High-index 1.74 Essilor FIT™ SV Aspheric Polycarbonate High-index 1.67 High-index 1.74 † Essilor Stylistic™ WRAP SV 1.50 Plastic Polarized Polycarbonate Polarized Polycarbonate Colors (nonpolarized) High-index 1.67 Polarized Hoya ID SV High-index 1.60 High-index 1.67 High-index 1.70 Total Payment to Provider from Member Single Vision (SV) Multifocal N/C 48 55 95 120 48 45 28 N/C N/C 36 N/C 55 64 112 130 55 55 32 N/C N/C 91 45 49 48 68 107 135 48 48 56 56 55 77 115 154 55 55 61 99 78 65 71 124 101 86 145 145 165 165 55 — 68 102 169 — — — 78 112 179 — — — 82 115 183 — — — 78 112 179 — — — 152 175 116 275 — — — — 145 165 177 — — — Options Specialty lenses continued Hoya ST28 IQ Plastic Polycarbonate Polycarbonate Polarized Trivex Hoya SV IQ Plastic Polycarbonate Polycarbonate Polarized Trivex Trivex Polarized High-index 1.67 Hoyalux Array Sync™ 5 Plastic † Phoenix High-index 1.60 High-index 1.67 Hoyalux Array Sync 8 Plastic † Phoenix High-index 1.60 High-index 1.67 Plastic tints Solid tint (excludes pink and rose) Gradient tint Glass tints and others Tinted glass (excludes pink and rose) Glass tint yellow Glass coating solid Glass coating gradient Photochromics Glass PBX or PGX Glass Thin & Dark † Plastic A: SunTech † Plastic B: Transitions®, PhotoViews™, LifeRx, ChangeRx®, Colormatic® † Plastic C: XTRActive † Plastic D: Transitions Vantage Miscellaneous Blended bifocal Mirror coating solid or gradient Factory scratch-resistant coating Premium scratch-resistant coating: Essilor TD2®, Hoya Clarity Shield Premium scratch-resistant coating: Essilor TD2 with Optifog® Technology Oversize 61 and above Facet (includes polishing) Ultraviolet (UV) treatment † Blu-Tech Groove Drill and/or notch Roll and polish/polish edges/ edge coating Occupational/double segment Executive bifocal (plastic only) Center thickness 1.5 or below Slab-off Prism Total Payment to Provider from Member Single Vision (SV) Multifocal — — — — 80 85 185 99 63 68 135 88 140 121 — — — — — — 73 80 87 108 — — — — 73 80 87 108 — — — — 13 15 13 15 18 50 27 27 27 67 31 31 23 37 72 77 34 58 83 88 115 120 125 157 — 44 16 49 44 16 29 29 48 48 14 58 15 — 12 27 14 64 15 20 12 27 13 13 — — N/C N/C N/C N/C N/C N/C N/C N/C * The member’s materials copayment covers single-vision, lined bifocal or lined trifocal lenses that are clear and nonaspheric and are made of standard glass or standard plastic. ** The member’s materials copayment covers single-vision or 22mm round-segment, aspheric-lenticular lenses at no additional payment. (Cataract/Aphakic) † symbol is used to indicate changes that are specific to the April 28, 2014, price list update. Changes include new options, options that have a new name and options that have changed in placement and /or pricing. continued on back > Options Total Payment to Provider from Member: Progressive lens availability Level 1 60 Essilor Adaptar, Essilor Super No-Line, Rodenstock Life SI, Signet Armorlite S/A Navigator, S/A Navigator Short, Sola Instinctive, † Vision Ease Outlook , Younger Image Level 2 71 AO Compact, Essilor Adaptar Digital, Essilor Adaptar Short Digital, Essilor Natural, Essilor Natural Digital, Hoyalux GP, Kodak Concise, † Seiko AF2, Sola Max, Sola VIP, † Vision Ease Illumina, X-Cel Freedom ID Level 3 82 AO Easy, Essilor Ideal, Essilor Ovation, Essilor Ovation Digital, Essilor Smallfit, Essilor Smallfit Digital, Hoyalux GP Wide, Kodak Precise, † Kodak Precise PB, Kodak Precise Short, † Kodak Precise Short PB, Rodenstock Classic Life, Rodenstock Classic Life XS, † Seiko Succeed, † Seiko Succeed WS Level 4 94 AO B’Active, Essilor Accolade, Essilor Ideal Short, Hoya Summit cd, Hoya Summit ecp, KBCo Fusion 1, KBCo Fusion 2, Optima Hyperview, † Seiko Supercede, Shamir Creation, † Shamir Element, Shamir Genesis, Shamir Piccolo, Shamir Piccolo Attitude, Sola Compact Ultra, Varilux Ellipse, Varilux Comfort, Varilux Comfort DRx, Varilux Comfort Short, Varilux Comfort Short DRx, Varilux Sport, † Vision Ease Novel, † Vision Ease Novella Level 5 135 Level 6 145 Definity, Definity Short, Essilor Accolade Freedom, Essilor Ideal Advanced, Essilor Ideal Advanced Wrap, Hoya Summit cd iQ, Hoya Summit ecp iQ, Kodak Concise Digital, Kodak Precise Digital, Kodak Precise Short Digital, † Seiko Supernal, Shamir FirstPAL, † Shamir InTouch, Shamir Spectrum, Varilux Ellipse 360, Varilux Comfort Enhanced, Varilux Physio, Varilux Physio DRx, Varilux Physio Short, Varilux Physio Short DRx Definity 3, Hoya iD LifeStyle, Hoya iD LifeStyle cd, † Hoyalux Array, † Hoyalux Array High Base, Kodak Unique, † Seiko Surmount, † Seiko Surmount WS, Shamir Autograph II, Shamir Autograph II Attitude, Shamir Golf, Varilux Physio 360, Varilux Physio Enhanced, Varilux Physio Short 360, † Varilux Stylistic Wrap Level 7 — Level 8 185 Level 9 — for internal use only Level 10 — Level 11 270 for internal use only † Hoya iD MyStyle, Varilux S Design, Varilux S Design Short, Varilux S Fit, Varilux S 4D Level A near-variable 49 Essilor Computer, Essilor Interview, Hoya TACT, Shamir Office, Sola Access Level B near-variable 80 Shamir Autograph II Office Standard 44 † Seiko Surpass ECP, Sharpview Plus, Standard AR 1 year Premium 60 Hoya HiVision, Hoya Premium AR, Hoya Premium with View Protect, Kodak CleAR, † Seiko Super Surpass ECP Elite 72 Crizal Easy UV, Hoya HiVision with View Protect Supreme 85 Crizal Alizé UV, Hoya Super HiVision, Kodak Clean’N’CleAR Diamond 105 Imperial 130 Crizal Avancé UV, Crizal SunShield UV, Crizal SunShield UV Mirrors, † Hoya Recharge, Hoya Super HiVision EX3 † Crizal Prevencia, Crizal Sapphire UV, Crizal UV with Optifog Technology for internal use only Definity 3 Plus, † Hoya iD InStyle, † Hoya iD LifeStyle Clarity, † Hoya iD LifeStyle Harmony, † Shamir Autograph III, Varilux Ipseo IV, Varilux Ipseo IV eyecode, Varilux Physio Enhanced Azio, Varilux Physio Enhanced eyecode, Varilux Physio Enhanced Fit, Varilux Physio Enhanced India † Near-variable lens styles Anti-reflective (AR) coating products † symbol is used to indicate changes that are specific to the April 28, 2014, price list update. Changes include new options, options that have a new name and options that have changed in placement and/or pricing. Prices subject to change. GN51693HV 1213
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