Vision Plan - Northwest Administrators, Inc.

October 1, 2003 - September 30, 2004

Information provided is in summary format.  Any difference between the summary provided and actual contract will be settled in favor of the contract.

SSD

In-Network

Out-Of-Network

Vision Network:

NBN Panel Providers

Non-Panel Providers

$0

Vision Exam:

     Time Limit

One every 365 days from the date of last like service

     Payment Limit

Paid at 100%

Up to $35 reimbursement

Frames:

     Time Limit

One every 730 days from the date of last like service

     Payment Limit

100% of allowed amount on a wide selection of frames

Up to $30 reimbursement

One pair of lenses every 365 days from the date of last like service

Elective Contact Lenses:

     Time Limit

Exam, fitting and contact lenses, in lieu of all other services, every 365 days from the date of last like service

     Payment Limit

$175

$90

Necessary Contact Lenses:

     Time Limit

One pair of contacts every 730 days from the date of last like service

     Payment Limit

100% of allowed

$200