Exhibit 1 - EyeMed Vision Summary of Benefits.pdf

additional complete pair of prescription eyeglasses non-covered items, including non-prescription sunglasses

40%

OFF

20%

OFF

SUMMARY OF BENEFITS

• 866.804.0982

• eyemed.com

• EyeMed Members App

• For LASIK, call

1.800.988.4221

Heads Up You may have additional benefits.

Log into eyemed.com/member to see all plans included with your benefits.

St Johns River Water Management District

Find an eye doctor (Insight Network)

VISION CARE

SERVICES

IN-NETWORK

MEMBER COST

OUT-OF-NETWORK

MEMBER REIMBURSEMENT

EXAM SERVICES

Exam $10 copay Up to $40 Retinal Imaging Up to $39 Not covered

CONTACT LENS FIT AND FOLLOW-UP

Fit and Follow-up - Standard $0 copay; contact lens fit and two follow-up visits Up to $40

Fit and Follow-up - Premium $0 copay; 10% off retail price, then apply $55 allowance

Up to $40

FRAME

Frame $0 copay; 20% off balance over $100 allowance Up to $70

STANDARD PLASTIC LENSES

Single Vision $15 copay Up to $30 Bifocal $15 copay Up to $50 Trifocal $15 copay Up to $70 Lenticular $15 copay Up to $70 Progressive - Standard $80 copay Up to $50 Progressive - Premium Tier 1 - 3 $100- 125 copay Up to $50 Progressive - Premium Tier 4 $80 copay; 20% off retail price less $120 allowance Up to $50

LENS OPTIONS

Anti Reflective Coating - Standard $45 Not covered Anti Reflective Coating - Premium Tier 1 - 2 $57 - 68 Not covered Anti Reflective Coating - Premium Tier 3 20% off retail price Not covered Photochromic - Non-Glass $75 Not covered Polycarbonate - Standard $40 Not covered Scratch Coating - Standard Plastic $15 Not covered Tint - Solid and Gradient $15 Not covered UV Treatment $15 Not covered All Other Lens Options 20% off retail price Not covered

CONTACT LENSES

Contacts - Conventional $0 copay; 15% off balance over

$100 allowance Up to $100

Contacts - Disposable $0 copay; 100% of balance over $100 allowance

Up to $100

Contacts - Medically Necessary $0 copay; paid in full Up to $210

OTHER

Hearing Care from Amplifon Network Up to 64% off 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

FREQUENCY ALLOWED FREQUENCY -

ADULTS

ALLOWED FREQUENCY - KIDS

Exam Once every calendar year Once every calendar year Frame Once every other calendar year Once every other calendar year Lenses Once every calendar year Once every calendar year Contact Lenses Once every calendar year Once every calendar year

(Plan allows member to receive either contacts and frame, or frames and lens services)

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. Allowances provide no remaining balance for future use within the same Benefit Frequency. 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, Policy number VC-19, form number M-9083, or Policy number VC-146, form number M-9184, in New York underwritten by Fidelity Security Life Insurance Company of New York, Policy Number VCN-1, form number MN-1, or Policy Number VCN-19, form number MN-28. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.

Ready to live your best EyeMed life?

There’s so much more to your vision benefits than copays and coverage. Get ready to see the good stuff for yourself.

Your network is the place to start See who you want, when you want. You have thousands of providers to choose from — independent eye doctors, your favorite retail stores, even online options.

Keep your eyes open for extra discounts Members already save an average 71% off retail using their EyeMed benefits,1 but our long list of special offers takes benefits even further.

Remember, you’re never alone We’re always here to help you use your benefits like a pro. Stay in-the-know with text alerts or healthy vision resources from the experts. If it can make benefits easier for you, we do it.

Create a member account at eyemed.com Everything is right there in one spot. Check claims and benefits, see special offers and find an eye doctor — search for one with the hours, location and brands you want. For maximum mobility, try the EyeMed Members App (Google Play or App Store).

PDF-2004-M-377

1 Based on weighted average of sample transactions; EyeMed Insight network/$10 exam copay/$10 materials copay/$120 frame or contact lens allowance.