LASIK EYE SURGERY

This benefit is self-funded by the Plan and covers LASIK Eye Surgery for all participants, subject to the following:

1. Only services provided by Griffin & Reed Eye Care will be covered. Your first visit will be with a Griffin & Reed Eye Care physician.
2. During your initial exam with a Griffin & Reed physician you will be tested to determine if you are a candidate for a LASIK Eye Surgery. If you are a candidate for surgery, the testing fee will be included in the overall benefit, otherwise the Plan will pay the cost.
3. If you are a candidate for LASIK Eye Surgery, the surgery will be done by a Griffin & Reed surgeon at the Griffin & Reed facility at the Horizon Laser Center. In some cases continued medical treatment from a Griffin & Reed physician may be necessary.
4. For LASIK eye surgery prescribed by a Griffin & Reed physician, the Plan pays 90% of the contract amount, up to a maximum total payment of $3,400 ($1,700 per eye).
5. Your cost will be $170.00 for each eye. $105.00 per eye must be paid to Griffin & Reed Eye Care, the remaining $65.00 per eye must be paid to Horizon Laser Center the day of the surgery.
6. As with other types of medical benefits, coverage is not available under this benefit for sight loss covered by workers compensation.
7. Griffin & Reed Eye Care and the Horizon Laser Center where surgery is performed are located at:

   651 Fulton Avenue
   Sacramento, California 95825
   (916) 483-2525