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<br /> <br />"!k <br />~~I' <br />CITY OF NORTH OLMSTED <br />VISION CARE AGREEMENT <br />"THIS CONTRACT IS BETWEEN THE CITY OF NORTH OLMSTED, OHIO <br />AND UNION EYE CARE CENTER, INC. FOR THE BENEFIT OF THE EMPLOYEES <br />OF THE CITY OF NORTH OLMSTED." <br />I. PLAN SUNIlKAItY <br />Union Eye Care Center, Inc. agrees to provide optometric eye <br />refractions, eyeglasses and contact lenses for eligible <br />employees and their dependents of the City of North Olmsted <br />Employees in accordance with the plan description. Eligible <br />dependents include the spouse and children up to the age of <br />19, or age 23 if dependent is a full time student. <br />II. PLAN DESCRIPTION - COVERAGE FREQUENCY <br />A. Eye examination <br />B. Spectacle lenses <br />C. Frames <br />D. *Contact lenses <br />- Once each 12 month period <br />- Once each 12-month period <br />- Once each 24-month period <br />- Once each 12 month period <br />III. COVERED VISION SERVICES - DEFINITIONS <br />A. Vision Examination - The examination includes a <br />determination as to the. need for correction of visual <br />acuity, prescribing the lenses, if needed and <br />confirmation of the appropriateness of any eyeglasses <br />obtained from the prescription. The vision examination <br />includes the following procedures: <br />1. History <br />2. Evaluation of visual acuity for eyeglasses <br />3. External examination of the eyes <br />4. Binocular measure <br />5. Ophthalmoscopic examination <br />6. Tonometry <br />7. Dilation when indicated <br />8. Summary and findings <br />*Contact lenses are in lieu of spectacle lenses. <br />1 <br />Rev. 07/17/09 <br />EXHIBIT <br />~ r~t7~l 4 - icy <br />