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<br /> VISION SERVICE ~ <br /> PRINCIPAL EXCLUSIONS AND LIMITATIONS OF BENEFITS <br /> EXTRA COST <br /> THIS VISION SERVICE PLAN IS DESIGNED TO COVER VISUAL NEEDS RATHER THAN <br /> COSMETIC MATERIALS. \~EN A COVERED PERSON SELECTS ANY OF THE FOLLOWING <br /> EXTRAS, THE PLAN WILL PAY THE BASIC COST OF THE ALLOWED LENSES, AND THE <br /> COVERED PERSON WILL PAY THE ADDITIONAL LABORATORY COST FOR THE EXTRAS PLUS <br /> A MODEST ADDITIONAL FEE. <br /> 1. BLENDED LENSES <br /> 2. CONTACT LENSES (EXCEPT AS NOTED ELSEWHERE HEREIN) <br /> 3. OVERSIZE LENSES <br /> 4. PHOTOCHROMIC LENSES; TINTED LENSES EXCEPT PINK #1 AND PINK #2 <br /> 5. PROGRESSIVE MULTIFOCAL LENSES <br /> 6. THE COATING OF THE LENS OR LENSES <br /> 7. THE LAMINATING OF THE LENS OR LENSES· <br /> 8. A FRAME THAT COSTS MORE THAN THE PLAN ALLOW~~CE <br /> THERE ARE ALSO CERTAIN LIMITATIONS ON LOW VISION CARE. <br /> NOT COVERED <br /> THERE IS NO BENEFI~ FOR PROFESSIONAL SERVICES OR MATERIALS CONNECTED WITH: <br /> 1. ORTHOPTICS OR VISION TRAINING AND ANY ASSOCIATED SUPPLEMENTAL TESTING; <br /> PLANO LENSES; OR TWO PAIR OF GLASSES IN LIEU OF BIFOCALS. <br /> 2. LENSES AND FRAMES F1~NISHED U~~ER THIS PLAN WHICH ARE LOST OR BROKEN <br /> WILL NOT BE REPLACED EXCEPT AT THE NORMAL INTERVALS WHEN SERVICES ARE <br /> OTHERWISE AVAILABLE. <br /> 3. MEDICAL OR SURGICAL TREATMENT OF THE EYES. <br /> 4. ANY EYE EXAMINATION, OR ANY CORRECTIVE EYE WEAR, REQUIRED BY AN <br /> EMPLOYER AS A CONDITION OF EMPLOYMENT. <br /> VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE <br /> OPINION OF OUR OPTOMETRIC CONSULTANTS, THIS IS NECESSA&Y FOR THE VISUAL <br /> WELFARE OF THE COVERED PERSON. <br /> -8- <br /> 1/87AB <br /> - ._,.. " <br />