HomeMy WebLinkAboutC26830 - Vision Service Plan (VSP) M� '�,II •.''l�,'r,•• ' " �
July 16, 2007
Lori Carney
Human Resources
City of Palm Desert
73-510 Fred Waring Drive
Palm Desert, CA 92260
RE: CONTRACT —VISION SERVICE PLAN
Dear Lori:
Enclosed is your Vision Service Plan Contract effective July 1, 2007. I have reviewed the
contract and found it to be accurate. Please retain the enclosed copy for your files.
If you have questions or need anything further, please don't hesitate to contact me at (310)
543-9995.
Sincerely,
Deirdre Dwane
Account Manager
enclosures
cc: Kristin Yokoyama, ABD
YY,:��-�1V
H�.\LIBRARY�TEAMS'�Gary Team�.Kathy�Renewal 2007�Gty Contract Letter-VSP.doc
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VISION SERVICE PLAN
3333 QUALITY DRIVE
RANCHO CORDOVA, CAL[FORNIA 95670
GROUP VISION CARE PLAN
Group Name CITY OF PALM DESERT
Plan Number 00408001
State of Dclivcry CALIFORNIA
Effective Date JULY 1, 2007
Plan Term TWENTY-FOUR (24) MONTHS
Premium Due Datc FIRST DAY OF MONTH
In consideration of the statements and agreements conlained in the Group Application
and in con�ideration of payment by the Group of the premiums as herein provided, VISION
SERVICE PLAN ("VSP") agrees to provide certain individuals under this Group Vision Care
Plan (`'Plan") the benefits provided herein, subject to the exceptions, limitations and exclusions
hereinalier set forth. This Nlan is delivered in and governed by the laws of the state of dclivery
and is subject to the terms and conditions recited on the subscquent pages hereof, including any
Exhibits or state-specific Addenda, which are a part of� his Plan.
Gary Brooks, Senior Vicc President, Operations
VSP-PLAN-5/07 07/02/07 Gmg
TABLE OF CONTENTS
I. DEFINITIONS....................................................................................................... 1
II. TERM, TERMINATION, AND RENEWAL .........................................................4
III. OBLIGA"I'iONS OF VSY.......................................................................................5
IV. OBLIGATIONS OF THE GROUP.........................................................................8
V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN ...................... 10
VI. ELIGIBILITY FOR COVERAGE........................................................................ 14
VII. CONTINUATION OF COVERAGE.................................................................... 17
VIII. ARBITRATION OF DISPUTES.......................................................................... 18
IX. NOTICES ............................................................................................................ 19
X. MISCELLANEOUS.............................................................................................20
EXHIBITA...................................................................................................................23
SCHEDULE OF BENEFITS..............................................................................23
EXHIBITB...................................................................................................................29
SCHEDULEOF PREMIUMS ...........................................................................29
ADDENDUM ...............................................................................................................30
ADDITIONAL BENEFTT - COVERED CONTACT LENSES..........................30
ADDENDUM ...............................................................................................................32
THE CALIFORNIA CONTINUATION BENEFITS..........................................32
I.
DEFINITIONS
Key tcrms uscd in this Ylan arc dctined:
1.O1. BI?NEFIT AUTHORIZATION: Authori�ation from VSP identifying thc
individual named a Co��ered Pcrson of VSP, and identifying those Plan Benef'its to which
Covered Pcrson is entitled.
1.02. CONFIDENTIAL MATTER: All contidential information concerning the
tnedical, personal, tinancial or business affairs of Covercd Persons obtained while providing Plan
Benefits hereunder.
I.03. COPAYMENTS: Any amounts required to t�e paid by or on behalf of a Covercd
Pcrson for Plan Bcncfits which are not fully covered.
1.04. COVERED PERSON: An Enrollee or Eligible Dependent who meets VSP's
eli�ibility criteria and on whose behalf Premiums have Y�een paid VSP, and who is covered under
this Plan.
1.05. ELIGIBLE DEPENDENT: Any legal dependent of an Enrollee of Group who
meets the criteria for eli�ibility established by Group and approved by VSP in Article VI of thi�
Ylan under which such Enrollee is covered.
1.06. EMERGENCY CONDITION: A condition, with sudden onset and acute
symptoms, that requires the Covered Person to obtain immediate medical care, or an unforeseen
occurrence calling for immediate, non-medical action.
1.07. ENROLLEE: An employee or member of Group who meets the criteria for
eligibility specified under Article VI. ELIGIBILITY FOR COVERAGE.
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1.08. EXPERIMENTAL NATURE: Procedure or lens that is not used universally or
accepted by the vision care profession, as determined by VSP.
1.09. GROUP: An employcr or other entity which contracts with VSP for coverage
under this Ylan in order to provide vision care coverage to its Enrollees and their Eligihle
Dependents.
1.10. GROUP APPLICATION: The form signed by an authorized representative of
the Group to signify the Group's intention to have its Enrollees and their Eligible Dependents
be:come Covered Persons of VSY.
l.l l. GROUP VISION CARE PI,AN (also, "THE PLAN"): Thc Plan issucd by
VSP to a Group, under which its Enrollees or members, and their Eli�ible Depcndents are
�ntiticd to be;come Covered Persons of VSP and receive Plan Benefits in accordance with the
tcrms of such Plan.
1.12. MEMRER DOCTOR: An optometrist or ophthalmologist licenscd and
otherwise qualified to practice vision care and/or provide vision care materials who has
contracted with VSP to provide vision care services and/or vision care materials on behalf of
Covered Persons of VSP.
1.13. NON-MEMBER PROVIDER: Any optomctrist, optician, ophthalmologist, or
othcr licensed and yualified vision care provider who has not contracted with VSP to provide
vision care services and/or vision care materials to Covered Persons of VSP.
1.14. PI,AN BENEFITS: The vision care services and vision care materials which a
Covcred Person is entitled to receive by virtue of coverage under this Plan, as defined in the
Schedule of Benefits attached hereto as Exhibit A.
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I.15. RENEWAL DATE: The date when the Plan shall rencw, or terminate if proper
notice is biven.
1.16. SCHEDULE OF BENEFITS: The document, auached hereto a� Exhibit A to
this Plan, which lists thc vi�ion care services and vision care materials which a Covercd P�rson is
entitled to rcceive under this Plan.
1.17. SCHEDULE OF PREMIUMS: The document, attached hereto as Exhibit B,
which states the payments to be made to VSP by or on bchalf of a Covered Per�on to entitle
him/her to Plan Benefits.
1.18. VISUALLY NECESSARY OR APPROPRIATE: Services and matcrials
medically or visually necessary to restore or mainlain a patient's visual acuity and health and for
which there is no less expcnsivc professionally acceptable alternative, as determined by VSP.
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II.
TERM, TERMINAI'ION, AND RENEWAI,
2.O1. Plan Term: This Plan is effective on the Effectivc Date and shall remain in
cffect for the Plan Tcrm. At the end of the Plan Term, thc Plan shall rcnew on a month to month
hasis unless citller party notities the other in writing, at least sixty (60) days before the end of lhe
Ylan Tertn that such party is unwilling lo rcn�w the Plan. If such notice is given, the Plan shall
tcrminate at 1 1:59 p.m. on the last day of the Plan Term unless the parties a�ree on its renewal of�
the Plan. If the Plan continues on a month to month basis after the Plan Term, either party may
terminate the Plan upon thirty (30) days advance noticc to the other party.
If VSP issues written renewal materials to Group at least sixty (60) days before thc cnd of
the Plan Term and Group fails to accept the new terms and/or rates in writing prior to the end of
the Plan Term, this Plan shall terminate at 1 1:59 p.m. on the last day of the Plan Term.
2.0?. Earlv Termination Provision: The Premium rate payable by Group to VSP
under this Plan is bascd on an assumption that V5P will receive thcse amounts over the full Plan
Term in order to cover costs associated with greater vision utilization that tends to occur during
the first portion of a Plan Term. [f Group terminates this Plan before the end of the Plan Term or
bef��re the end of any subsequent renewal terms, for any reason other ihan material breach by
VSP, Group shall be liable for the le�ser of� any deficit incurred by VSP or the remaining
payments which Group would have paid for the full tcrm of this Agreement. A deficit incurred
by VSP will be calculated by subtracting the cost of incurred and outstanding claims from thc
premiums reccived by VSP from Group. Group agrees to pay VSP within thirty-onc (3 l) days of
notification of the amount due.
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III.
OI3LIGATIONS OF VSP
3.01. Covera�e of Covered Persons: VSP will enroll for coverage each eligible
Enrollee and his/her Eli�iblc Depcndcnts, if dependent coverage is provided, all of who shall be
referred to upon enrollment as `Covered Persons." To institute coverage, VSP may require
Group to complctc, sign and forward to VSP a Group Application alon� with information
regarding Enrollces and Eligible Dependents, and all applicable premiums. (Refer to VI.
ELIGIBILITY FOR COVERAGE for further details.)
Following the enrollrnent of the Covered Persons, VSP will provide Group with Member
BeneCt Summaries for distribution to Covcrcd Persons. Such Member Benetit Summaries will
summarize the terms and conditions set forth in this Plan.
3.0?. Provision of Plan Benefits: Through its Member poctors (or through other
liccnsed vision care providers where a Covered Person is eligible for, and chooses to receive
Plan Benefits from a Non-Member Provider) VSP shall provide Covered Persons such Plan
Bene�ts listed in the Schedule of Benefits, Exhibit A hereto, as may be Visually Necessary or
Appropriate, subject to any limitations, exclusions, or Copayments therein stated. Bene�t
Authorization musl be obtained prior to a Covered Person obtaining Ylan Benerits from a
Member poctor. When a Covered Yerson seeks Plan Benefits from a Member I)octor, the
Covered Person must schedule an appointment and identify himsclf as a VSP Covercd Person so
thc Member poctor can obtain Benefit Authorization from VSP. VSP shall provide Benefit
Authorization to the Member poctor to authorize the provision of Plan Benefits to the Covered
Person. Each Benefit Authorization will contain an expiration date, stating a specific time period
for the Covered Person to obtain Plan Benefits. VSP shall issue Benefit Authoruations in
accordance with the latest eligibility information furnished by Group and the Covered Person's
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past service utilization, if any. Any BrneCt Authorization so issued by VSP shall constitute a
certitication to the Membcr poctor that payment will be: made, irrespective of a later loss of
eligibility of thc Covercd Person, provided Plan Benefits are received prior to the Benefit
Authorization cxpiration date.
VSY shall pay or deny claims ior Plan Benefits provided to Covcred Pcrsons, less any
applicable Copayment, within a reasonable time but not more than thirty (30) calendar days atter
VSP has received a completed claim, unless special circumstances require additional tirne. In
such cases, VSP may obtain an extension of fifteen (1 S) calendar days of this time limit by
providing notice to the claimant of the reasons for the extension.
3.03. Determination of Visual Necessity: Plan Benefits are covcrcd only when and to
the extent that they are deemcd Visually Necessary or Appropriate for the proper treatmenl of a
Covered Person's condition. Questions involving nccessity or appropriateness of treatment shal(
be decided by the Member poctor (or Non-Member Provider) responsible for the Covered
Person's care and are subject to rcview and final determination by VSP. Any objections of a
Covered Person relating to such decisions may be made to VSP at the address given herein and
in accordance with VSP's grievance procedures (See Paragraphs S.OS and 5.06).
3.04. Provision of Information to Covered Persons: Upon rcyucst, VSP shall makc
available to Covered Persons necessary information describin� Ylan Benet7ts and how to use
them. A copy of this Plan shall be placed with Group and also will be madc available at the
offices of VSP for any Covered Persons. VSP shall provide Group with an updated list of
Member poctors' names, addresses, and telephone numbers fi�r distribution to Covered Persons
twice a year. Covered Persons may also obtain a copy of the Member poctor directory through
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contacting VSP's Customer Service Department's toll-tree Customer Servicc telcphone line,
VSP's Web site at www.vsp.com, or by written rcquest.
3.05. Preservation of Confidentialitv: VSP shall hold in strict confidence all
Confidential Matters and exercise its best efforts to prevent any of its employees, Member
Doctors, or agentti, irom disclosing any Confidential Matter, except to the extent that such
disclosure is necessary to rnable any of the above to perform their obligations under this Plan,
includin� but not limited to sharin� information with medical inf��rmation burcaus, or complying
with applicable law. Covered Persons and/or Groups that want more information on VSP's
Confidentiality policy may obtain a copy of the policy by contacting VSP's Customer Ser��icc
Departmcnt or VSP's Web site at www.v�p.com.
3.06. Emer�ency Vision Care: When vision care is necessary tor Emergency
Conditions, Covered Persons may obtain Plan Benefits by contacting a Memher poctor or Non-
Member Provider. No prior approval from VSP is required for Covered Person to obtain vision
care for Emergency Conditions of a medical nature. However, services for medical conditions,
including emergencies, are covered by VSP only under the Acule EyeCare and Supplemental
Primary EyeCare Plans. If Group has not purchased one of these plans, Covered Persons are not
covered by VSP for medical services and should contact a physician under Covered Persons'
medical insurance plan for care. For emergcncy conditions of a non-medical nature, such as lost,
broken or stolen glasses, the Covered Person should contact VSP's Customer Service Department
for assistance. Reimbursement and eligibility are subject to the terms of this Plan.
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IV.
ORI,I(�ATIONS OF THE GROUP
4.01. Identification of Eligible Enrollees: An Enrollee is eligible for coverage undcr
this Plan if he/she satisfies the enrollment criteria specified in Paragraph 6.01(a) and/or as
mutually agreed to by VSY and Group. By the Effective Date of this Plan, Group shall providc
VSP with cligibility information, in a mutually agrecd upon format and rnedium, to identify all
Enrollees who are elibible for coverage under this Plan as of that date. Thcreafter, Group shall
supply to VSP by the last day of cach month, eligibility information sufficient to identify all
Enrollecs to t�e added to or deleted from VSP's coverage rosters for the next month. The
eligibility information shall include designation of each Enrollee's family status if dependent
coverage is provided. Upon VSP's request, Group shall make available for inspection records
regarding the coverage of Covered Persons under this Plan.
4.02. Pavment of Premiums: By the last day of each month, Group shall remit to VSP
thc premiums payable fi�r the ncxt month on bchalf of each Enrollee and Eligible Dependents, if
any, to t�e covered under this Plan. The Schedule of Premiums incorporated in this Plan as
Exhibit B provides the premium amount for each Covered Person. Only Covered Person� for
whom premiums are actually received by VSP shall be entitled to Plan Benefits under this Plan
and only for the period for which such payment is received, subject to the grace period provision
below. If payment for any Covered Person is not received on time, VSP may terminate all rights
of�such Covered Person. Such rights may be reinstated only in accordance with the requirements
of this Plan.
VSP may change the premiums set forth in Exhibit B (Schedule of Premiums) by giving
Group at least sixty (60) days advance written notice. No change will be made during the Plan
Term unless there is a change in the Schedule of Benefiits or there is a material change in Plan
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terms or conditions, provided any such change is mutually agreed upon in writing hy VSP and
Group.
Notwithstanding the above, VSP may increasc premiums duri�ig a Plan Term by the
amount of any tax or a�sestimeni no� now in eff�ect but subsequenily levied by any taxing
authority, which is attributable to premiums VSP received from Group.
4.03. Grace Period: Group shall be allowed a grace period of thirty-onc (3 I) days
following the premium payment due date io pay premiums due under this Plan. During said
grace period, this Plan shall remain in full force and eff'ect for all Covered Persons of Group.
VSP will consider late payments at the time of Plan renewal. Such payment may impact Group's
prcmium ratcs in future Plan Tcrms.
If Group fails to make any premiums payment due by the end of any grace period, VSP
may notify Group that the premiums payment has not been made, that coverage is canceled and
that Group is responsible for payment for all Plan Benefits provided to Covered Persons after the
last period for which premiums were paid in full, including the grace period through the effective
date of�termination. Group shall also be responsible for any legal and/or collection fees incurred
by VSP to collect amounts due under this Plan.
4.(k�. Distribution of Required Documents: Group shall distribute to Enrollees any
disclosure l��rms, plan summaries or other material required to be: given to plan subscribers by
any regulatory authority. Such materials shall be distributed by Group no later than thirty (30)
days after thc receipt thereof, or as required under state law.
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V.
OBI,IGATIONS OF COVERED PERSONS UNDER THE PI,AN
5.01. General: By this Plan, Group makes covcrage available to its Enrollees and thcir
Eligible Depcndents, if dependent coverage is provided. However, this Plan may be amended or
terminated by agrecment betwern VSP and Group as indicated herein, without thc consent or
concurrence of Covered Persons. This Plan, and all Exhibils, Riders and attachments hcreto,
constitute VSP's sole and entirc undertaking to Covered Persons under this Plan.
As conditions of coverage, all Covered Persons under this Plan have thc following
obligations:
5.02. Coqavment for Services Received: Wherr, as indicated in Exhibit A (Schedule
of Benefits), Copayment� are required for certain Plan Benefits, Copayments shall be the
personal responsibility of the Covered Person receiving the care and must be paid to the Member
Doctor the date services are rendered.
5.03. Obtaining Services from Member poctors: Benetit Authorization must be
obtained prior to receiving Plan Benefits from a Member poctor. When a Covered Person seeks
Plan Benefits, the Covered Per�on must select a Member poctor, schedule an appointment, and
identify himself as a Covered Person so the Member poctor can obtain Benefit Authorization
from VSP. Should the Covered Person receive Plan Benefits from a Member poctor without
such Benetit Authorization, then for the purposes of those Plan Benefits provided to the Covered
Person, the Member Uoctor will t�e considered a Non-Member Provider and the benefits
available will be limited to those for a Non-Member Provider, if�any.
5.04. Submission of Non-Member Provider Claims: lf Non-Member Provider
coverage is indicated in Exhibit A (Schedule of Benefits), written proof(receipt and the Covered
Person's identitication information) of all claims for services received from Non-Member
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Providers shall F�e submitted by Covercd Persons to VSP within one hundred eighty (180) days
of the date of servicc. VSP may reject such claims filed more than one hundred eighty ( I 80)
days after the date of service.
Failure to submit a claim within this time period, however, shall not invalidate or reduce
the claim if it was not reasonably possiblc to submit the claim within such time period, provided
the claim was submitted as soon as reasonably possible and in no event, except in absencc of
legal capacity, later than one year from the required date of one hundred eighty (180) days after
the date of service.
5.05. Complaints and Grievances: Covered Persons shall report any complaints
and/or grievances to VSP at the address given herein. Complaints and grievances are
disagreements regarding access �o care, quality of care, treatmcnt or service. Complaints and
gricvances may be submitted to VSP verbally or in writing. A Covered Person may submit
written comments or supporting documentation concernin� his complaint or grievance to assist
in VSP's rcview. VSP will resolve the complaint or grievance within thirty (30) days after
receipt.
5.06. Claim Denial Appeals: If, under the terms of this Plan, a claim is denied in
whole or in part, a request may be submitted to VSP by Covered Person or Covered Person's
authorized representative for a full review of the denial. Covered Person may designate any
person, including his/her provider, as his/her authorized representative. References in this
section to "Covered Person" include Covered Person's authorized representative, where
applicable.
a) Initial Appeal: The reyuest must be made within one hundred eighty
(180) days following denial of a claim and should contain sufficient information to identify the
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Covered Person for whom the claim was denied, including thc VSP Enrollee's name, the VSP
Enrollee's Member ldentiCcation Number, the Covered Yerson's name and date of birth, the
provider of services and the claim number. The Covered Person may review, during normal
working hours, any docurnents held by VSN pertinent to the deniaL The Covcred Yerson may
also submit written comments or supporting documentation concerning the claim to assist in
VSP's review. VSP's determination, including specific reasons for the decision, shall be
provided and communicated to the Covered Person within thirty (30) calcndar days after reciept
of a request for appeal from the Covered Person or Covcrcd Person's authorized representative.
b) Second Level AppeaL• If the Covered Person disagrees with �he response
to the initial appeal of the claim, the Covered Person has a righl to a second level appeal. Within
sixty (60) calendar days after receipt of VSP's response to the initial appeal, the Covered Person
may submit a second appeal to VSP along with any pertinent documentation. VSP shall
communicate its final determination to the Covered Person in compliance with all applicable
state and federal laws and regulations and shall include the specific reasons for the
detcrmination.
c) Other Remedies: When Covered Person has completed the appeals
process stated herein, additional voluntary alternativc dispute resolution options may tx�
available, including mediation, or Group should advise Covered Person to conlact the U.S.
Department of Labor or the state insurance regularory agency for details. Additionally, under the
provisions of ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1 l32(a)(1)(B)], Covered Person has the
right to bring a civil action when all available levels of review of denied claims, including the
appeals process, have been completed, the claims were not approved in whole or in part, and
Covered Person disagrees with the outcome.
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5.07. Time of Action: No action in law or in equity shall be brought to rccover on the
Plan prior to the Covercd Yerson exhaustin� his/her grievance rights under this Plan and/or prior
to the expiration ot� sixty (60) days after the claim and any applicable invoices have been filed
with VSP. No such action shall be; brought after lhc expiration of six (6) years from the last date
that the claim and any applicable invoices were submitted to VSP, in accordance with the tcrms
of this Plan.
5.08. Insurance Fraud: Any Group and/or person who intends to defraud, knowingly
facilitates a fraud or submits an application or files a claim with a false or deceptive statement, is
guilty of insurance fraud. Such an act is grounds for immedia�e termination of the Plan for the
Group or individual that committed the fraud.
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vr.
ELICIRILITY FOR COVERAGE
6.01. Eligibilitv Criteria: Individuals will bc accepted for coverage hereunder only
upon mecting all the applicable requirements sct forth below.
(a) Enrollees: To be cligible for coveragc, a person must:
( 1) currently he an employee or member of the Group, and
(2) meet the criteria established in the coverage criteria mutually agreed
upon by Group and VSP.
(b) Eligible Dependents: If dcpendcnt coverage is provided, the persons
cligible for dependent coverage are:
(1) the legal spouse of any Enrollee, and
(2) any unmarried child of an Enrollee, including any natural child from
the moment of birth, Iegally adopted child from the moment of placement fior adoption with the
Enrollee, or other child for whom a court holds the Enrollee responsible; and
(A) for whose support the EnroUee is legally responsible and who
has not yet attained the age of 19 years, or
(B) who is chiefly dependent upon the Enrollee for support, has
not yet attaincd the age of 23 years, and is currently enrolled as a full-time student in good
standing actively pursuing a degree or certiCcate at a recognized educational institution.
(3) as further defined by Group.
[f a dependent, unmarried child prior to attainment of the prescribed age for termination
of eligibility becomes, and continues to be, incapable of self-sustaining employment because of
mental or physical disability, that Eligible Dependent's coverage shall not terminate so long as he
remains chiefly dependenl on the Enrollee for supporl and the Enrollee's coverage remains in
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forcc; PROVIDEU that satisfactory proof of the dependcnt's incapacity can bc furnishcd to VSP
within thirty-one (31) days o1�the date the Eligible Dependcnt's coverage would have otherwise
terminated or at such other times as VSP may reyuest proof, but not morc frcquently than
annually.
6.0?. Documentation of Eli�ibilit}�: Persons satisfying the coverage requircmcnts
undcr either of the above criteria shall be eligible it`.
(a) for an Enrollee, the individual's name and Social Security Number have been
reported by Group to VSP in the manner provided hereunder, and
(b) for changes to an Eligible Dependent's status, the change has been reported by
the Group to VSP in the manner provided herein. As stated in Paragraph 4.01 abovc, VSP may
elect to audit Group's records in order to verify cligibility of Enrollees and dependents and any
errors. Subject to the terms of Paragraph 4.03 above, only persons on whose t�ehalf premiums
have been paid for the current period shall tx; cntitled to Plan Benefits hereunder. If a clerical
error is made, it will not affect the coverage a Covered Person is entitled under the Plan.
6.03. Retroactive Eligibilitv Chan�es: Retroactive eligibility changes are limited to
sixty (60) days prior to the date notice of any such requested change is received by VSP. VSP
may refuse retroactive termination of a Covered Pcrson if Plan Benefits have been obtained by,
or authorized for, the Covered Person after the effective date of the requested termination.
6.04. Chan�e of Participation ReQuirements, Contribution of Fees, and EligibiGtv
Rules: Composition of the Group, percentage of Enrollees covcred under the Plan, and Group's
contribution and eligibility requirements, are all material to VSP's obligations under this Plan.
During the term of this Plan, Group must provide VSP with written notice of changes to its
composition, percentage of Enrollees covered, contribution and eligibility requirements. Any
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change which materially affects VSP's obligations under this Ylan must be agreed upon in
writing between VSY and Group and may constitutc a material change to thc terms and
conditions of this Plan tor purposes of Paragraph 4.02. Nothing in this section shall limit
Group'� ability to add Enrollees or Eligible Dcpendents undcr the terms of this Plan.
6.05. Chan�e in Familv Status: In the event Group is notified of any change in a
Covered Person's family status �by marriage, the addition (c.g., ncwborn or adopted child) or
deletion of Dependent, etc.] Group shall provide notice of such change to VSP via the next
eligibility listing required under Paragraph 4.01. If notice is given, the changc in the Covered
Person's status will be effective on the first day of the month following the change request, or at
such later date as may be requested by or on behalf of the Covered Person. Notwithstanding any
other provision in this section, a newborn child will be covered during the thirty-one (3 I) day
period aher birth, and an adopted child will be covered for the thirty-one (31) day period after
the date the Enrollce or Enrollee's spouse acquires the right to control that child's health care. To
continue coverage ti�r a newborn or adopted child bcyond the initial thirty-one (31) day period,
the Group must be properly notified of the Enrollee's change in family status and applicable
prcmiums must be paid to VSP.
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VII.
CONTINUATION OF COVERAGE
7.01. COBRA: Thc Consolidatcd Ornnibus Budget Reconciliation Act of 1985
(COBRA) requires that, under c:ertain circumstances, health plan benefits available to an
Enrollee and his or her Eli�ible Dependents be made available tor purchase by said persons upon
the occurrence of a COBRA-qualif�ying event. lt; and only to the exlent, COBRA applies, VSP
shall make the statutorily-required continuation coverage available for purchase in accordance
with COBRA.
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VIII.
ARBITRATION OF DISPUTES
8.01. Dispute Resolution: Any dispute or yuestion arising between VSP and Group or
any Covered Person im�olving the application, interpretation, or performance under this Plan
shall be seuled, if possible, by amicablc and informal negotiations. This will allow such
opportunity as may be appropriate under the circumstances for tact-finding and mediation. [f
any issue cannot Ix resolved in this fashion, it shall be submitted to arbitration.
8.02. Yrocedure: The procedure f��r arbitration hereunder shall hc; conducted pursuant
to the Rules of the American Arbitration Association.
8.03. Choice of Law: if anv matter arises in connection with this Plan which t�ecomes
the subject ot�arbitration or legal process, the law of the State of Uelivery of the Plan shall he the
applicable law.
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IX.
NOTICES
9.01. Required Notices: Any notices required to be given undcr this Plan to either
Group or VSP shall be in writing and delivered by United States First Class Mail. Notices sent
to Group will he mailed to the address shown on the Group Application. Notices sent to VSP
shall bc; sent to the address shown on this Plan. Notwithstanding the above, any notices may be
hand-delivered by cither party to an appropriate representative of the other parly. The party
effecting hand-dclivery bears the burden to prove delivery was made, if questioned.
- 19-
X.
MISCELLANEOUS
10.01. Entire Plan: This Plan, the Group Application, the Evidence of Covcrage, and
all Exhibits, Riders and auachments hereto, and any amendments hereto, contititute the entire
agreement of the partics and supersedes any prior understandin�s and agreements between thern,
either written or oral. Any change or amendment to the Ylan must be approved by an officer ot�
VSP and attached hereto to be valid. No agent has the authority to change this Plan or waive any
of its provisions. Communication materials prepared by Group for distribution to Enrollees do
not constitute a part of this Plan.
10.02. Indemnitv: VSP agrees to indemnify, defend and hold harmless Group, its
shareholders, directors, orficers, agents, employecs, successors and assigns from and against any
and all liability, claim, loss, injury, cause of action and expense (including defiense costs and
legal fees) or any naturc whatsocver arising from the failure of VSP, its of�cers, agents or
employees, to perform any of the activities, duties or responsibilities specified herein. Group
agrees to indemnify, defend and hold harmless VSP, its members, shareholders, directors,
ofticers, agents, employees, successors and assigns from and against any and all liability, claim,
loss, injury, cause of action and expense (including defen�e costs and legal fecs) of any nature
whatsocver arising or resulting from the failure of Group, its officers or employees to perform
any of the duties or responsibilities specified herein.
10.03. I,iability: VSP arranges for the provision of vision care services and materials
through agreernents with Member poctors. Member poctors are independent contractors and
responsible for exercising independeni judgement. VSP does not itself directly furnish vision
care services or supply materials. Under no circumstances shall VSP or Group be liable for the
- 20-
negligcncc, wrongful acts or omissions of any doctor, laboratory, or any other person or
organization performing scrvices or �upplying materials in conncction with this Plan.
10.04. Assi�nment: Ncither thi� Plan nor any of the rights or ohligations of either of thc
parties hereto may be assigned or transferred without the prior written consent of both parties
hereto cxcept as expressly authorited herein.
10.05. SeverabilitV: Should any provision of this Plan bc; dcclared invalid, the
rcmaining provisions shall remain in full force and effect.
10.06. Governing Law: This Plan shall t�e govcrned by and construed in accordance
with applicable federal and state law. Any provision that is in confilict with, or not in compliance
with, applicable federal or state statutes or regulations is hereby amended to conform with the
requirements of such statutes or regulations, now or hereafter existing.
10.07. Gender: All pronouns used herein are deemed to refer to the masculine,
feminine, neuter, singular, or plural, as the identity(ies) of the person(s) may require.
10.08 F.qual Opnortunitv: VSP is an Equal Opportunity and Affirmative Action
employer.
10.09. Grievances/Comnlaints: The California Department of Managed Health Care is
responsible for regulating health care service plans. If you have a grievance against your health
plan, you should Crst tclephone your health plan at (800) 877-7195 and use your health plan's
grievance process before contacting the Department. Utilizing this grievance procedure does not
prohibit any potential legal rights or remedies that may be available to you. If you need help
with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by
your health plan, or a grievance that has remained unresolved for more than 30 days, you may
call the Department for assistance.
- 21-
You may also be eligiblc for an Independent Medical Revicw (IMR). If you are eligiblc
tor IMR, thc [MR process will provide an impartial review of� medical decision� madc hy a
hcalth plan related to the medical necessity of a proposed service or treatment, coverage
decisions for treatments that are experimental or investi�,ational in nature and payment disputes
for cmergency or urgent medical s�rvices.
The Department also has a toll-irce telcphone number (1-888-HNTO-2219) and a TDD
line (1-877-688-9891) for the hearing and speech impaired. The Department's Internet Web site
(http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions
online. The plan's grievance process and the Department's complaint review process arc in
addition to any other dispute resolution procedures that may be available to Covered Persons,
and the failure to use these procedures does not preclude Covered Person'� use of� any other
rcmedy providcd by law.
10.10. Communication Materials: Communication materials crcated by Group which
relate to this vision care Plan must adhere to VSP's Member Communication Guidelines
distributed to Group by VSP. Such communication materials may tx sent to VSP for review and
approval prior to use. VSP's review of such materials shall be limited to approving the accuracy
of Plan Benefits and shall not encompass or constitute certification that Group's materials mect
any applicable legal or regulatory requirements, including but not limited to, ERISA
requirements.
- 22-
EXHIBIT A
VISION SERVICE PI,AN
SCHEDULE OF BENEFITS
Enhanced Pian B
('�ENERAI,
This Schedule list� the vision care services and vision care materials to which Covered Yersons
of VSP are entitled, subject to any Copayments and other conditions, limitations and/or
exclusions stated herein. If Plan Benefits are availablr for Non-Member Provider services, as
indicatcd by the reimbursement provisions below, vision care services and vision care materials
may be received from any licensed optometrist, ophthalmologist, or dispensing optician, whether
Member poctors or Non-Member Providers. This Schedule forms a part ot�the Plan or Policy to
which it is attached.
When Plan Benefits are received from Member poctors, benefits appearing in the first column
bclow are applicable �ubject to any Copayments as stated below. When Plan Benefits are
available and received from Non-Member Providers, the Covered Person is reimbursed for such
benefits according to the schedule in the second column below less any applicable Copayments.
COPAYMENT
The benefits described herein are available to cach Covered Person subject only to payment of
the applicable Copayment by the Covered Person. Copayments are required for Plan Benefits
rcceived from Member poctors and Non-Member Providers. Covered Persons must al�o follow
the proper procedures for obtaining Benefit Authorization.
A Copayment amount of$10.00 shall be payable by the Covered Person to the Member poctor
at the time services are rendered.
PLAN BF,NEFITS
MEMBF,R DOCTOR NON-MEMRER
BENEFIT PROVIDER BENEFIT
VISION CARE SERVICES
Eve Examination Covcrcd in Full" Up to $ 45.00��"
Complete initial vision analysis which includes an appropriate examination of visual functions,
including the prescription of corrective eyewear where indicated.
Subsequent regular eye examinations every 12 months.
*Less any applicable Copayment.
_ �3_
VISION CARE MATF,RIAI,S
�'IEMBF.R DOCTOR NON-MEMI3ER
BENF,FIT PROVIDER I3ENEFIT
Lenses
Sin�le Vision Covered in full'�` Up to � 45.00=�=
Bifocal Covcrcd in fiull" Up to $ 65.00'
Trifocal Covcrcd in full�` Up to $ 85.(�"
Lenticular Covcrcd in full�` Up to � 125.00*
Available once every 12 monthti.
Frames Covcred up to Plan Up to $ 47.00"
Allowance"
Available once every 24 months.
�"Less any applicablc Copayment.
Lenses and frames include such professional services as are necessary, which shall include:
• Prescribin� and ordering proper lenses;
• Assisting in the selection of frames;
• Verifying the accuracy of the �nished lenses;
• Proper �tting and adjustmenl of framcs;
• Subsequent adjustments to frames to maintain comfort and efficiency;
• Progress or follow-up work as necessary.
- 24-
CONTACT LENSES
Contact lenses are available oncc every 12 months in lieu of all other lens and frame bencGts
available herein. When contact lenses are obtained, the Covcred Person shall not be eligible for
Icnses and frames again for 12 months.
Visually Necessary — When Visually Necessary contact lenses are obtained from a Membcr
Doctor, they will be covered in full with prior authorization from VSP. When Visually
Necessary contact lcnses are obtaincd from a Non-Member Provider, VSP will provide an
allowance toward the cost as outlined below. Coverage for Visually Necessary contact lenses
regardless of whether they are obtained from a Mcmher poctor or Non-Mcmber Provider are
subject to review and authorization from VSP's Optometric Consultants.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees and Materials Professional Fees and Materials
Covcred in full„ Up to $250.00'�
Elective - Contact lenses for other than Visually Necessary circumstances
MEMBER DOCTOR NON-MEMBER
RENEFIT PROVIDER BENEFIT
Professional Fees** and Materials Professional Fees and Materials
Up to $I 20.00 Up to $105.00
Covered - Covered contact Icnses are provided as an additional t�;nefit under the plan. Details
of this coverage are attached hereto as an addendum.
MEMBER DOCTOR NON-MEMBER
RENEFIT PROVIDER BENEFIT
Professional Fees and Materials Professional Fees and Materials
Covcred in fuIIX Up to $250.00*
'�Subject to Copaymcnt
*�`Additional discount applies to Member poctor's usual and customary professional fees for
contact lens evaluation and fitting (see section on Additional Discounts below).
- 25-
ADllITIONAL llISCOUNT
Each Covered Person shall be entitled to recei��e a discount ot�twenty percent (20�I�)'` toward thc
purchase of non-covered matcrial� from any Member poctor when a complete pair of glasses is
dispensed. Also, Covered Pcrsons shall be entitled to receive a discount of fiftcen percent (I S�/c)
off of contact lens cxamination services ti-orn any Member poctor.�`�`
Discounts are applied to the Mcmber poctor's usual and customary fees for such service� and arc
unlimited for 1? months on or f��llowing thc date of the patient's last eye exam.�`�`
L[MITAT'IONS:
• Discounts do not apply to vision care benefitti obtained from Non-Member Providers.
• 20�Ic discount applies to complete pairs of glasses only.
• Discounts do not apply if prohibited by thc manufacturcr.
• Discounts do not apply to sundry items: e.g., contact lens solutions, cases, cleaning
products or repair� of spcctacle lenses or frames.
*Note: For Plan B patients (12/12/24), the 20��c discount applies to the frame on the off year.
''=''=Professional judgment will be applicd when evaluating prescriptions written by another
provider. Member poctors may request a discounted additional exam.
- 2�-
LOW VISION BENEFIT
The Low Vision bencfit is available to Covered Persons who have severe visual problems that
are not correctablc with re�ular lenses and is subjcct ro prior approval by VSP Consultants.
MEMI3ER DOCTOR NON-MEMBER
BENEFIT PROVIDER RENEFIT
Supplementary Testing Covcred in Full Up to �1?5.00
Complete low vision analysis/diagnosis, which includes a comprehensive examination of
visual functions, includin� the prescription of corrective eyewear or vision aids where indicated.
Supplemental Care Aids 75°Ic of Cost 75�� of Cost
Subsequent low vision aids as Visually Necessary or Appropriate.
Copayment for Supplcmental Aids: 25�/c payable by Covercd Person.
Renefit Maximum
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
NON-MEMBER PROVIDER BENEFIT
Low Vision t�enefits secured from a Non-Member Provider are subject to the same time limits
and Copayment arrangements as described above for a Member poctor. The Covered Person
should pay the Non-Member Provider his full fee. The Covered Person will be reimbursed in
accordance with an amount not to exceed what VSP would pay a Member poctor in similar
circumstances. NOTE: Thcrc is no assurance that this amount will be within the 25°Ir;
Copayment feature.
- 27-
EXCLUSIONS AND i,IMITATIONS OF RENEFITS
PATIENT OPTIONS
This Plan is designcd to cover visual need� rather than cosmetic materials. When the Covcred
Pcrson select� any of the followin� extras, the Ylan will pay the basic cost of the allowed Ienses,
and the Covered Yerson will pay the additional costs for the options.
• Optional cosmrtic proccsses.
• Anti-reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmctic lenscs.
• Laminated lenses.
• Oversize lenses.
• Progressive multifocal lenscs.
• Photochromic Ienses; tintcd lenses except Pink #1 and Pink #2.
• UV (ultraviolet) protected lenses.
• Certain limitations on low vision care.
• A frame that costs ►nore than the Plan allowance.
• Contact lenses (except as noted elsewhcre herein).
NOT COVERED
Thcre is no benefit for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing; plano lenses (less than
a ±.50 diopter power); or two pair of glasses in lieu of bifocals;
• Replacement of lenses and frames furnished under ihis Plan which are lost or broken, except
at the normal intervals when services are otherwise available;
• Medical or surgical treatment of the eyes;
• Corrective vision treatment of an Experimental Nature;
• Costs for services and/or materials above Plan Benefit allowances;
• Services and/or materials not indicated on this Schedule as covered Plan Benefits.
VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE
OPINION OF VSP's OPTOMETRIC CONSULTANTS, IT IS NECESSARY FOR THE
VISUAL WELFARE OF THE COVERED PERSON.
- 28-
F,XHIBIT B
VISION SEKVICE PLAN
SCHEDUI.F, OF PREMIUNIS
Enhanced Plan B
VSP shall be entitled to receive premiums for each month on bchalf of each Enrollce and his/her
Eligible Dependents, if any, in the amounts specified lxlow:
� 26.45 per month t��r each eligible Enrollee (includes coverage for Eligible Dependents)
NOTICE: The premium under this Plan is subject to changc, upon renewal (after the end of the
Initial Plan Term or any subsequent Plan Term) or upon change of the Schedule of Bene�ts or a
material change in any other terms or conditions of the Plan.
- 29-
ADDF,NDU�1
VISION SERVICE I'I.AN
ADI)I 1'IONAI. BENEFIT - COVERED CONTACT I,ENSES
13ENEFITS
Persons covered under this additional benefit are entitled to contact lenscs which are referred to
by VSP as "covered" as opposed to those which are de�ned as "necessary" under the standard
coveragc.
A. Covered Persons may receive professional services and the contact lenses associated
therewith from a Member poctor, if in the opinion of the Member poctor lhe patient can
successfully wear contact lenses. This Plan covers the initial fitting period of up to 90
days. This may be extended at the discretion of the doctor. THIS BENEFIT DOES NOT
AFFECT, NOR IS IT AFFECTED BY. THE COVERED PERSON'S ELIGIBILITY
FOR SPECTACLE LENSES AND FRAMES UIVDER THE REGULAR PLAN.
B. For each Covered Person seekin� services under this benefit, there shall be a Copayment
as follows:
TYPE OF LENS FITTING AMOUNT OF COPAYMENT
Disposable contact lenses, $ 50.00
including daily disposable contact lenses
BECAUSE OF THE UNIQUE NATURE OF FITTING CONTACT LENSES, EXPERIENCE
HAS SHOWN THAT THERE MUST BE SUBSTANTIAL PATIENT MOTIVATION. THERE
IS ALSO SIGNIFICANT TiME INVOLVED ON THE DOCTOR'S PART - WHETHER OR
NOT THE PROCEDURE IS SUCCESSFUL. FOR THESE REASONS, THE COPAYMENT IS
NOT REFUNDABLE TO THE COVERED PERSON IN ANY CASE.
C. While the professional contact lens services received under this program is essentially
prepaid for most types of fittings, there are certain additional features, such as artistically
painted contact lenses, for which the Covered Person may be required to make an
additional paymcnt.
- 30-
EXCLUSIONS
Thc followinb items arc not covered undcr this Plan:
• Orthokcratology
• Replacement of lost or damaged len�es
• Modifications of lenses
• Routine maintenance such as polishing
• Refitting (change in lens dcsign) after the initial Gtting
- this will be the responsibility of the Covercd Pcrson
NON-MEMBER PROVIDERS
Covered contact lens scrvices secured from a doctor who is NOT a member of the VSP panel are
subject to the same titne limits and Copayments described herein. The Covered Person should
pay the Non-Member Provider his full fee. Covered Persons will be reimbursed in accordance
with a schedule as �hown under "EXHIBTT A - SCHEDULE OF BENEFITS" THERE IS NO
ASSURANCE THAT THE SCHEDULE WILL BE SUFFTCIENT TO PAY FOR THE
SERVICES RECEIVED.
CONTACT LENSES, ONCE FURNISHED UNDER THIS PLAN, CAN BE REPLACED
ONLY WITH PR10R AUTHORIZATION BY VSP, BUT IN NO EVENT MORE
FREQUENTLY THAN EVERY 12 MONTHS.
- 31-
ADDENDUM
VISION SERVICE PI,AN
THE CALIFORNIA CONTINUATION RENEFITS
REPLACEMENI' ACT OF 1997 (CAL-COBRA)
Pursuam �o California Health and Safety Code Section l�66.25, the following section is herchy
incorporated into the Group Vision Carc Plan, if, and only to the extent Cal-COBRA applies to
thc parties to this Plan:
The California Continuation Benefits Replacement Act of 1997 (Cal-COBRA) requires health
care service plans providin� contracted coverage to employers with 2 to 19 eligiblc employees to
offer continuation coverage for purchase by qualified beneficiaries upon the occurrence of a
qualifying event. VSP and Group are subject to the following obligations in connection with
continuation coverage:
1. Group agrees to provide VSP with notice of any employee who has had a "yualifying
event", within 31 days of the yualifying cvcnt. A "qualifying evenr' means any of the following
events that, but for the election of continuation coverage provided thereunder, would result in a
loss of coverage under the group benefit plan to a qualitied lx:neticiary:
• The death of the covered cmployee.
• The tcrmination or reduction of hours of the covered employee's employment, except that
termination for gross misconduct does not constitute a yualifying event.
• The divorce or legal separation of the covered employee from the covered employee's
spouse.
• The loss of dependent status by a dependent cnrolled in the group benefit plan.
• With respect to a dependent only, the covcred employee's eligibility for coverage under Title
XVIII of the United States Social Security Act (Medicare).
Within 14 days of receipt of the foregoing notice of a qualifyin� event irom Group, VSP will
send to the qualified beneficiary's last known address, as provided by Group, the necessary
benefits information, premium information, enrollment forms, and instructions to allow the
qualified beneficiary to formally elect continualion coverage.
2. Group agrees to notify qualified bene�ciaries currently receiving continuation coverage,
whose continuation coverage will terminate under one group benefit plan prior to the end of the
period thc qualified beneficiary would have remained covered under Cal-COBRA, as specified
in Health and Safety Code Section 1366.27, a minimum of 30 days prior to the termination, of
the quali�ed beneficiary's ability to continue coverage under a new group benefit plan for the
balance of the period the qualified beneficiary would have remained covered under the prior
group benefit plan. Group agrees to provide qualified beneficiaries subject to thi� paragraph
with the necessary benefits information, premium information, enrollment forms, and
instructions to allow the qualified beneCciary to continue coverage. This information shall tx
sent to the qualified beneficiary's last known address, as provided by the plan currently
providing continuation coverage to ihe qualified beneficiary.
- 32-
� �
�
•
;��
, ,_ _� ., ,`E�`C;� -:`'.
EVIDENCE OF COVERAGE
&
DISCLOSURE FORM
Provided hy:
VISION 5ERVICE PLAN
3333 Quality Drive, Rancho Cordova, CA 95670
(916) 851-5000 (800) 877-7195
TH1S EVIDENCE OF COVERAGE AND DISCLOSURE FORM DTSCLOSES THE TERMS AND CONDITIONS OF
COVERAGE. PLEASE READ THE FORM COMPLETELY AND CAREFULLY. INDIVIDUALS WITH SPECIAL
HEALTHCARE NEEDS SHOULD CAREFULLY READ THOSE SECTIONS THAT APPLY TO THEM. ALL
AI'PLICANTS HAVE A RIGHT TO REVIEW THE EVIDENCE OF COVERAGE AND DISCLOSURE FORM PRIOR
TO ENROLLMENT.
CARISK-00890 07/02/07 Gmg
To be filled in by employer in the event this document is used to develop a Summary Plan Description:
NAME OF EMPLOYER:
NAME OF PLAN:
PRINCIPAL ADDRESS:
EMPLOYER I.D.#:
PLAN#:
PLAN ADMINISTRATOR:
ADDRESS:
PHONE NUMBER:
REGISTERED AGENT FOR SERVICE OF LEGAL PROCESS, IF DIFFERENT FROM PLAN ADMINISTRATOR:
ADDRESS:
THIS EVIDENCE OF COVERAGE AND DISCLOSURE FORM CONSTITUTES ONLY A SUMMARY OF THE TERMS AND CONDITIONS OF
COVERAGE. THE PLAN CONTRACT ITSELF SHOULD BE CONSULTED TO DE7ERMINE GOVERNING TERMS AND CONDITIONS OF
COVERAGE.
DEFINITIONS:
ANISOMETROPIA A condition of unequal refractive state for the two eyes, one eye requiring a different lens correction than the
other.
BENEFIT AUTHORIZATION Authorization issued by VSP identifying the individual named as a Covered Person of VSP, and identifying those
Plan Benefits to which a Covered Person is entitled.
COPAYMENTS Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits which are not fully
covered.
COVERED PERSON An Enrollee or Eligible Dependent who meets VSP's eligibility criteria and on whose behalf Premiums have been
paid to VSP,and who is covered under this plan.
ELIGIBLE DEPENDENT Any legal dependent of an Enrollee of Group who meets the criteria for eligibility established by Group and
approved by VSP under section VI. ELIGIBILITY FOR COVERAGE of the Group Plan document maintained by
your Group Administrator under which such Enrollee is covered.
EMERGENCY CONDITION A condition, with sudden onset and acute symptoms, that requires the Covered Person to obtain immediate
medical care,or an unforeseen occurrence requiring immediate, non-medical action.
ENROLLEE An employee or member of Group who meets the criteria for eligibility specified under section VI. ELIGIBILITY
FOR COVERAGE of the Group Plan document maintained by your Group Administrator.
EXPERIMENTAL NATURE Procedure or lens that is not used universally or accepted by the vision care profession,as determined by VSP.
GROUP An employer or other entity which contracts with VSP for coverage under this plan in order to provide vision care
coverage to its Enrollees and their Eligible Dependents.
KERATOCONUS A development or dystrophic deformity of the cornea in which it becomes coneshaped due to a thinning and
stretching of the tissue in its central area.
-1-
MEMBER DOCTOR An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision
care materials who has contracted with VSP to provide vision care services andlor vision care materials on behalf
of Covered Persons of VSP.
NON-MEMBER PROVIDER Any optometrist, optician, ophthalmologist, or other licensed and qualified vision care provider who has not
contracted with VSP to provide vision care services and/or vision care materials to Covered Persons of VSP.
PLAN BENEFlTS The vision care services and vision care materials which a Covered Person is entitled to receive by virtue of
coverage under this plan, as defined on the enclosed insert or in the Schedule of Benefits attached as Exhibit A
to the Group Plan document maintained by your Group Administrator.
PREMIUMS The payments made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits, as stated in
the Schedule of Premiums attached as Exhibit B to the Group Plan document maintained by your Group
Administrator.
RENEWAL DATE The date on which this plan shall renew or terminate if proper notice is given.
SCHEDULE OF BENEFlTS The document, attached as Exhibit A to the Group Plan document maintained by your Group Administrator,which
lists the vision care services and vision care materials which a Covered Person is entitled to receive by virtue of
this plan.
SCHEDULE OF PREMIUMS The document,attached as Exhibit B to the Group Plan document maintained by your Group Administrator,which
states the payments to be made to VSP by or on behalf of a Covered Person to entitle him(her to Plan Benefits.
VISUALLY NECESSARY Services and materials medically or visually necessary to restore or maintain a patienYs visual acuity and health
OR APPROPRIATE and for which there is no less expensive professionally acceptable alternative.
ELIGIBILITY FOR COVERAGE
Enrollees: To be eligible for coverage, a person must currently be an employee or member of the Group, and meet the criteria established in the
coverage criteria mutually agreed upon by Group and VSP.
Eligible Dependents: If dependent coverage is provided, the persons eligible for coverage as dependents shall include the legal spouse of any
Enrollee, and any unmarried child of an Enrollee who has not attained the limiting age as shown on the enclosed insert, including any natural child
from the moment of birth, legally adopted child from the moment of placement for adoption with the Enrollee,or other child for whom a court holds
the Enrollee responsible.
A dependent, unmarried child over the limiting age as shown on the enclosed insert may continue to be eligible as a dependent if the child is
incapable of self-sustaining employment because of inental or physical disability, and chiefly dependent upon the Enrollee for support and
maintenance.
ANNUAL ENROLLMENT/DISENROLLMENT
Except for new Enrollees joining this plan, Enrollees and Eligible Dependents shall have the right to becane covered or cancel coverage once each
year during the thirty (30) day period beginning sixty (60) days prior to the anniversary of the effective date of this plan (or as may otherwise be
allowed by mutual agreement between the Group and VSP). Any such coverage or cancellation of coverage may be accomplished only by Group
giving VSP written notice thereof on behalf of the Enrollee or Eligible Dependent before the end of the prescribed thirty{30)day period and will take
effect on the anniversary date following receipt of such notice.
PREMIUMS
Your Group is responsible for payments to VSP of the periodic charges for your coverage. You will be notified of your share of the charges, if any,
by your Group. The entire cost of the program is paid to VSP by your Group.
-2-
PROCEDURES FOR USING THIS PLAN
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE
MAY BE OBTAINED.
1. When you desire to obtain Plan Benefits from a Member poctor, you should coniact a Member poctor or VSP. A list of names,addresses,and
phone numbers of Member poctors in your geographic location can be obtained from your Group, Plan Administrator, or VSP. If this list does
not cover the geographic area in which you desire to seek services,you may call or write the VSP office nearest you to obtain one which does.
2. If you are eligible for Plan Benefits, VSP will provide Benefit Authorization directly to the Member poctor. If you contact a Member poctor
directly,you must identify yourself as a VSP member so the doctor knows to obtain Benefit Authorization from VSP.
3. When such Benefit Authorization is provided by VSP and services are performed prior to the expiration date of the Benefit Authorization,this will
constitute a claim against this plan in spite of your termination of coverage or the termination of this plan. Should you receive services from a
Member poctor without such Benefit Authorization or obtain services from a provider who is not a Member poctor, you are responsible for
payment in full to the provider.
4. You pay only the Copayment (if any) to the Member poctor for the seroices covered by this plan. VSP will pay the Member pocto�directly
according to their agreement with the doctor. VSP reimburses its Member poctors on a fee-for-service basis. There are no incentives or
financial bonuses paid to Member poctors for services covered under this plan.
Note: If you are eligible for and obtain Plan Benefits from a Non-Member Provider, you should pay the provider his full fee. You will
be reimbursed by VSP in accordance with the Non-Member Provider reimbursement schedule shown on the enclosed insert,less any
applicable Copayments.
5. In emergency conditions, when immediate vision care of a medical nature such as for bodily trauma or disease is necessary, Covered Person
can obtain covered services by contacting a Member poctor(or Out-of-Network Provitler if the attached Schedule of Benefits indicates Covered
Person's Plan includes such coverage). No prior approval from VSP is requiretl for Covered Person to obtain vision care for Emergency
Conditions of a medical nature. However, services for medical conditions, including emergencies, are covered by VSP only under the Acute
EyeCare and Primary EyeCare Plans. If coverage for one of these pfans is not indicated on the attached Schedule of Benefits or Addendum,
Covered Person is not covered by VSP for medical services and should contact a physician under Covered Person's medical insurance plan for
care. For emergency conditions of a non-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's
Customer Service Department for assistance.
Emergency vision care is sub}ect to the same benefit frequencies,plan allowances,Copayments and exclusions stated herein. Reimbursement
to Member poctors will be made in accordance with their agreement with VSP.
6. In the event of termination of a Member poctor's membership in VSP, VSP will remain liable to the Member poctor for services rendered to you
at the time of termination and permit Member poctor to continue to provide you with Plan Benefits until the services are completed or until VSP
makes reasonable and appropriate arrangements for the provision of such services by another authorized doctor.
BENEFIT AUTHORIZATION PROCESS
VSP authorizes Plan Benefits according to the latest eligibility information fumished to VSP by Covered Person's Group and the level of coverage
(i.e. service frequencies,covered materials, reimbursement amounts, limitations,and exclusions)purchased for Covered Person by Group under this
Plan. When Covered Person requests services under this Plan, Covered Person's prior utilization of Plan Benefits will be reviewed by VSP to
determine if Covered Person is eligible for new services based upon Covered Person's Plan's level of coverage. Please refer to the attached
Schedule of Benefits for a summary of the level of coverage provided to Covered Person by Group.
Prior Authorization
Certain Plan Benefits require VSP's prior authorization before such Plan Benefits are covered. VSP's prior authorization determinations are based
upon criteria developed by optometric and ophthalmic consultants and approved by VSP's Utilization Management Committee and Board of
Directors.
A. Initial Determination: VSP will approve or deny requests for prior authorization of seroices within three(3)business days of receipt of the
request from the Covered Person's doctor. In the event that a prior authorization cannot be resolved within the time indicated,VSP may, if
necessary, extend the time for decision by no more than three(3)business days.
-3-
B. Appeals: If VSP denies the doctor's request for prior authorization, the doctor, Covered Person or the Covered Person's authorized
representative may request an appeal of the denial. Please refer to the section on Claim Appeals, below,for details on how to request an
appeal. VSP shall provide the requestor with a final review determination within thirty (30) calendar days from the date the request is
received. A second level appeal, and other remedies as described below, is also available. VSP shall resolve any second level appeal
within thirty (30) calendar days. Covered Person may designate any person, including the provider, as Covered Person's authorized
representative.
For more information regarding VSP's criteria for authorizing or denying Plan Benefits,please contact VSP's Customer Service Department.
BENEFITS AND COVERAGES
Through its Member poctors, VSP provides Plan Benefits to Covered Persons as may be Visually Necessary or Appropriate, subject to the
limitations, exclusions, and Copayment(s)described herein. When you wish to obtain Plan Benefits from a Member poctor, you should contact the
Member poctor of your choice, identify yourself as a VSP member, and schedule an appointment. If you are eligible for Plan Benefits, VSP will
provide Benefit Authorization for you directly to the Member poctor prior to your appointment.
IMPORTANT: The benefits described below are typical services and materials available under most VSP plans. However,the actual Plan
Benefits provided to you by your Group may be different. Refer to the attached Schedule of Benefits andlor Disclosure to determine your
specific Plan Benefits.
1. Eye Examination: A complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of
corrective eyewear where indicated. Each Covered Person is entitled to a Eye Examination as indicated on the enclosed insert.
2. Lenses: The Member poctor will order the proper lenses necessary for your visual welfare. The doctor shall verify the accuracy of the finished
lenses. Each Covered Person is entitled to new lenses as indicated on the enclosed insert.
3. Frames: The Member poctor will assist in the selection of frames,properly fit and adjust the frames,and provide subsequent adjustments to
frames to maintain comfort and efficiency. Each Covered Person is entitled to new frames as indicated on the enclosed insert.
4. Contact lenses: Unless otherwise indicated on the enclosed insert,contact lenses are available under this Plan in lieu of all other lens and
frame benefits described herein.
When you obtain Visually Necessary contact lenses from a Member poctor, professional fees and materials will be covered as indicated on the
enclosed insert with prior authorization from VSP. Coverage for Visually Necessary contact lenses regardless of whether they are
obtained ftom a Member poctor or Non-Member Provider is subject to review and authorization from VSP's optometric consultants.
If you select contact lenses for other than Visually Necessary circumstances, they will be considered Elective contact lenses. When Elective
contact lenses are obtained from a Member poctor, VSP will provide an allowance toward the cost of professional fees and materials. A 15°-0
discount shall also be applied to the Member poctor's usual and customary professional fees for contact lens evaluation and fitting. Contact
lens materials are provided at the Member poctor's usual and customary charges.
5. If you elect to receive vision care services from one of the Member poctors, Plan Benefits are provided subject only to your payment of any
applicable Copayment. If your Plan includes Non-Member Provider coverage and you choose to obtain Plan Benefits from a Non-Member
Provider, you should pay the Non-Member Provider his full fee. VSP will reimburse you in accordance with the reimbursement schedule shown
on the enclosed insert, less any applicable Copayment. THERE IS NO ASSURANCE THAT THE SCHEDULE WILL BE SUFFICIENT TO PAY
FOR THE EXAMINATION OR THE MATERIALS. Availability of services under the Non-Member Provider reimbursement schedule is subject to
the same time limits and Copayments as those described for Member poctor services. Services obtained from a Non-Member Provider are in
lieu of obtaining services from a Member poctor and count toward plan benefit frequencies.
-4-
6. Additional Discount: Each Covered Person shall be entitled to receive a discount of twenty percent(20°0)'toward the purchase of non-covered
materials from any Member poctor when a complete pair of glasses is dispensed. Also,Covered Persons shall be entitled to receive a discount
of fifteen percent(15°0)off of contact lens examination services from any Member poctor."
Discounts are applied to the Member poctor's usual and customary fees for such services and are unlimited for 12 months on or following the
date of the patient's last eye exam."
LIMITATIONS:
Discounts do not apply �o vision carc bc;nef�its obtained tro►n Non-Member Pro��iders.
?O�I discount applies to complete pairs o1�glasses only.
I)iscounts do nol apply if prohibited by thc manufacturer.
Uiscounts do not apply to sundry items: e.g., contact lens solutions, cases, cleaning products or repairs of
spectacle lenses or framcs.
'Note: For Plan B patients(12/12/24),the 20°io discount applies to the frame on the off year.
"Professional judgment will be applied when evaluating prescriptions written by another provider. Member poctors may request a discounted
additional exam.
7. Low Vision Services and Materials(applicable only if included in your Plan Benefits outlined on the enclosed insert): The Low Vision Benefit
provides special aid for people who have acuity or visual field loss that cannot be corrected with regular lenses. If a Covered Person falls within
this category, he or she will be entitled to professional services as well as ophthalmic materials including but not limited to supplemental testing,
evaluations, visual training,low vision prescription services, plus optical and non-optical aids,subject to the frequency and benefit limitations as
outlined on the enclosed insert. Consult your Member poctor for details.
COPAYMENT
The benefits described herein are available to you subject only to your payment of any applicable Copayment(s)as described in this booklet and on
the enclosed insert.ANY ADDITIONAL CARE, SERVICE AND/OR MATERIALS NOT COVERED BY THIS PLAN MAY BE ARRANGED BETWEEN
YOU AND THE DOCTOR.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
This Plan is designed to cover visual needs rather than cosmetic materials.If you select any of the following extras,this Plan will pay the
basic cost of the allowed lenses,and you will be responsible for the additional costs for the options,unless the extra is defined as a Plan
Benefit in the enclosed Schedule of Benefits insert.
• Optional cosmetic processes.
• Anti-reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
• Oversize lenses.
• Photochromic lenses,tinted lenses except Pink#1 and Pink#2.
• Progressive multifocai lenses.
• UV(ultraviolet)protected lenses.
• Certain limitations on low vision care.
-5-
NOT COVERED
There is no benefit under this plan for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing;plano lenses(less than±.50 diopter power); or 1wo pair of glasses in lieu
of bifocals.
• Replacement of lenses and frames furnished under this plan which are lost or broken except at the normal intervals when services are
otherwise available.
• Medical or surgical treatment of the eyes.
• Corrective vision treatment of an Experimental Nature.
• Costs for services and/or materials above Plan Benefit allowances indicated on the enclosed insert.
• Services/materials not indicated as covered Plan Benefits on the enclosed insert.
LIABILITY IN EVENT OF NON-PAYMENT
IN THE EVENT VSP FAILS TO PAY THE PROVIDER.YOU SHALL NOT BE LIABLE FOR ANY SUMS OWED BY VSP OTHER THAN THOSE NOT
COVERED BY THE POLICY.
COMPLAINTS AND GRIEVANCES
If Covered Person ever has a question or problem,Covered Person's first step is to call VSP's Customer Service Department.The Customer Service
Department will make every effort to answer Covered Person's question and/or resolve the matter informally. If a matter is not initially resolved to the
satisfaction of a Covered Person,the Covered Person may communicate a complaint or grievance to VSP orally or in writing by using the complaint
form that may be obtained upon request from the Customer Service Department. Complaints and grievances include disagreements regarding
access to care, or the quality of care, treatment or service. Covered Persons also have the right to submit written comments or supporting
documentation concerning a complaint or grievance to assist in VSP's review.VSP will resolve the complaint or grievance within thirty(30)days after
receipt.
Claim Payments and Denials
A. Initial Determination: VSP will pay or deny claims within thirty(30)calendar days of the receipt of the claim from the Covered Person or
Covered Person's authorized representative. In the event that a claim cannot be resolved within the time indicated VSP may, if necessary, extend
the time for decision by no more than fifteen(15)calendar days.
B. Request for Appeals: If a Covered Person's claim for benefits is denied by VSP in whole or in part,VSP will notify the Covered Person in
writing of the reason or reasons for the denial.Within one hundred eighty(180)days after receipt of such notice of denial of a claim, Covered Person
may make a verbal or written request to VSP for a full review of such denial.The request should contain sufficient information to identify the Covered
Person for whom a claim for benefits was denied, including the name of the VSP Enrollee, Member ldentification Number of the VSP Enrollee, the
Covered Person's name and date of birth,the name of the provider of services and the claim number.The Covered Person may state the reasons
the Covered Person believes that the claim denial was in error. The Covered Person may also provide any pertinent documents to be reviewetl.
VSP will review the claim and give the Covered Person the opportunity to review pertinent documents,submit any statements,documents,or written
arguments in support of the claim, and appear personally to present materials or arguments. Covered Person or Covered Person's authorized
representative should submit all requests for appeals to:
VSP
Member Appeals
3333 Quality Drive
Rancho Cordova,CA 95670
(800)877-7195
VSP's determination, including specific reasons for the decision, shall be provided and communicated to the Covered Person within thirty (30)
calendar days after receipt of a request for appeal from the Covered Person or Covered Person's authorized representative.
When Covered Person has completed all appeals mandated by the Employee Retirement Income Security Act of 1974 (°ERISA"), additional
voluntary altemative dispute resolution options may be available, including mediation and arbitration. Covered Person should contact the U. S.
Department of Labor or the State insurance regulatory agency for details. Additionally, under ERISA (Section 502(a)(1)(B)) [29 U.S.C.
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1132(a)(1)(B)], Covered Person has the right to bring a civif (court) action when all available levels of denied claims, including the appeal process,
have been completed,the claims were not approved in whole or in part,and Covered Person disagrees with the outcome.
C. Review by the Department of Managed Health Care: The Califomia Department of Managed Health Care is responsible for regulating
health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at(800)877-7195 and use
your health plan's grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights
or remetlies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily
resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You
may also be eligible for an Independent Medical Review (IMR�. If you are eligible for IMR. the IMR process will provide an impartial review of
medical decisions made by a health plan related to the medical necessity of a proposed service or treatment,coverage decisions for treatments that
are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free
telephone number(1-888-HMO-2219)and a TDD line(1-877-688-9891)for the hearing and speech impaired. The DepartmenYs Internet Web site
http://www.hmohelp.ca.gov has complaint forrns, IMR application forms and instructions online.
ARBITRATION
Any dispute or question arising between VSP and Group or any Covered Person involving the application, interpretation, or performance under this
plan shall be settled, if possible, by amicable and informal negotiations. This will allow such opportunity as may be appropriate under the
circumstances for fact-finding and mediation. If any issue cannot be resolved in this fashion, it shall be submitted to arbitration. The procedure for
arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration Association.
SECOND MEDICAL OPINIONS
• All requests for a second medical opinion shall be directed,in writing,to:
Vision Service Plan
Clinical Consultant
Health Care Services Division
3333 Quality Drive
Rancho Cordova,CA 95670
• The Clinical Consultant will review each request and respond within twenty(20)days of receipt of the written request.
• The requesting patient shall provide all evidence supporting the request for a second metlical opinion when requested by the Clinical
Consultant.
• A request for a second medical opinion shall be granted when it is determined by the Clinical Consultant,based on information provided by the
Enrollee and the original examining Member poctor,that the initial examination was insufficient to ascertain the visual health problems of the
patient.
• In no circumstance will a second medical opinion be granted if the patienYs initial vision examination was performed by a Non-Member Provider.
TERMINATION OF BENEFITS
Terms and cancellation conditions of this plan are shown on the enclosed insert. Plan Benefits will cease on the date of cancellation of this plan
whether the cancellation is by Group or by VSP due to non-payment of Premium. If service is being rendered to you as of the terrnination date of
this plan,such service shall be continued to completion, but in no event beyond six(6)months after the termination date of this plan.
INDIVIDUAL CONTINUATION OF BENEFlTS
This program is available to groups of a minimum of ten (10) employees and is, therefore, not available on an individual basis. When a Group
terminates its coverage,individuai coverage is not avaiiable for Enrollees of the Group who may desire to retain their coverage.
THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985(COBRA)
The Consolidated Omnibus Budget Reconciliation Act of 1985(COBRA)requires that, under certain circumstances, health plan benefits available to
an eligible Enrollee and his or her Eligible Dependents be made available for purchase by said persons upon the occurrence of a COBRA-qualrfying
event. If, and only to the extent COBRA applies,VSP shall make the statutorily-required continuation coverage available for purchase in accordance
with COBRA.
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VlSION SERVICE PLAN
3333 Quality Drive
Rancho Cordova, CA 95670
Group Name: CITY OF PALM DESERT
Plan Number: 00408001
Effective Date: JULY 1, 2007
Plan Term: TWENTY-FOUR (24) MONTHS
V/S/ON CARE PLAN
D/SCLOSURE FORM AND EVIDENCE OF COVERAGE
PLAN ADM/N/STRATOR: LORI CARNEY
(NAME)
73510 FRED WARING DR
(ADDRESS)
PALM DESERT, CA 92260
(CITY, STATE, ZIP)
MONTHLYPREM/UM: YOUR GROUP IS RESPONSIBLE FOR PAYMENT TO VISION
SERVICE PLAN OF THE PERIODIC CHARGES FOR YOUR
COVERAGE. YOU WILL BE NOTIFIED OF YOUR SHARE OF THE
CHARGES, IF ANY, BY YOUR GROUP.
ELIG/BILITY: ENROLLEES & ELIGIBLE DEPENDENTS: UNMARRIED DEPENDENT
CHILDREN ARE COVERED TO AGE 19 OR TO AGE 23 IF FULL-TIME
STUDENTS. THE WAITING PERIOD lS THE SAME AS YOUR OTHER
HEALTH BENEFITS.
PLAN AND SCHEDULE: ENHANCED PLAN B
EXAMINATION: ONCE EVERY 12 MONTHS
LENSES: ONCE EVERY 12 MONTHS
FRAMES: ONCE EVERY 24 MONTHS
TERM, TERM/NAT/ON AND RENEWAL: AFTER THE PLAN TERM, THIS PLAN WILL CONTINUE ON A MONTH
TO MONTH BASIS OR UNTIL TERMINATED BY EITHER PARTY
GIVING THE OTHER SIXTY(60)DAYS PRIOR WRITTEN NOTICE.
TYPE OF ADM/N/STRATION: BENEFITS ARE FURNISHED UNDER A VISION CARE PLAN
PURCHASED BY THE GROUP AND PROVIDED BY VISION SERVICE
PLAN (VSP) UNDER WHICH VSP IS FINANCIALLY RESPONSIBLE
FOR THE PAYMENT OF CLAIMS.
VSP'S ADDRESS/S: VISION SERVICE PLAN
3333 QUALITY DRIVE
RANCHO CORDOVA, CA 95670
-8-
� SCHEDULE OF BENEFITS
GENERAL
This Schedule lists the vision ca�e services and vision care materia/s to which Covered Persons of VSP are entitled,
subject to any Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available
for Non-Member Provider services as indicated by the reimbursement provisions below, vision care services and vision
care materials may be received from any licensed optometrist, ophtha/mo/ogist, or dispensing optician, whether Member
Doctors or Non-Member Providers.
When Plan Benefits are received from Member poctors, benefits appearing in the first column be/ow are applicable
subject to any Copayment(s) as stated below. When Plan Benefits are available and received from Non-Member
Providers, you are reimbursed for such benefits according to the schedule in ihe second column below less any
applicable Copayment.
PLAN BENEFITS MEMBER DOCTOR BENEFIT NON-MEMBER PROV/DER BENEF/T
VISION CARE SERVIGES
Vision Examination Covered in Full' Up to$ 45.00"
VISION CARE MATER/ALS
Lenses
Single Vision Covered in Full" Up to$ 45.00'
Bifoca/ Covered in Full' Up to$ 65.00"
Trifocaf Covered in Full' Up io$ 85.00'
Lenticu/ar Covered in Full' Up to$ 125.00'
Frames Covered up to Plan Allowance" Up fo$ 47.00'
CONTACT LENSES
Visual/y Necessary
Professional Fees and Materials Covered in Full* Up to$ 250.00'
Elective
Professional Fees"and Materials Up to$ 120.00 Up to$ 105.00
Covered Contact Lenses
Professional Fees and Materials Covered in Fu�l" Up to$ .00`
'Covered Contact Lenses are provided as an additional benefit under this Plan subject to a $50.00 Copayment
and further subject to all of ihe oiher plan limitations. For more informafion regarding this Additional Benefii,
p/ease see the Covered Contact Lens Addendum attached hereto.
When contact lenses are obtained, the Covered Person shall not be eligible for�enses and frames again for 12 months.
*Subject to Copayment, if any.
*•Additional discount applies to Member poctor's usual and customary professionai fees tor coniaci /ens
evaluation and fiKing,
-9-
COPAYMENT
A Copayment amounf of$10.00 shall be payable by the Covered Person to the Member poctor or Non-Member poctor at
the time services are rendered.
LOW VIS/ON
Professionai services, as necessary, for severe visuai problems not corrected with regular/enses, including:
Supplemental Testing Covered in Full Up to $125.00
(includes evaluation, diagnosis and prescription of vision aids where indicated)
Supplemental Aids 75% of cost 75% of cost
Maximum allowable for all Low Vision benefiis of$1000.00 every two(2)years.
ADD/T/ONAL D/SCOUNT
Each Covered Person shall be entitled to receive a discount of twenry percent(20%)'toward the purchase of non-covered
materials from any Mem6er poctor when a complete pair of glasses is dispensed. Also, Covered Persons shall be
entif/ed to receive a discount of fifteen percent(15%) off of cantact lens examination services from any Member poctor."
Discounts are applied to ihe Member poctor's usual and customary fees for such services and are unlimited for 12
months on or following the date of ihe patient's last eye exam."
LIMITATIONS:
Discounls do not apply to vision care be:nefits obtained from Non-Membcr Providers.
20�'/c discount applies to complete pairs of glasses only.
Discounts do not apply if prohibitcd by the manufacturer.
Discounts do not apply to sundry items: e.g., con�act lens solutions, cases, cleaning products or repairs of
spectacle lenses or frames.
"Note: For Plan B patients (12112124), ihe 20% discount applies to the frame on ihe off year.
"Professional judgment will be applied when evaluating prescriptions written by another provider. Member poctors may
request a discounied additional exam.
THIS EVIDENCE OF COVERAGE CONSTITUTES ONLY Q SUMMARY OF THE VISION PLAN. THE VISION PLAN DOCUMENT
MUST BE CONSULTED TO DETERMINE THE EXACT TERMS AND CONDITIONS OF COVERAGE.
-10-
Exhibit C
ADDITIONAL BENEFIT RIDER
COVERED CONTACT LENSES
GENERAL
This Rider lists additional vision care benefits to which Covered Persons of VISION SERVICE PLAN are entitled, subject to any Copayments and
other conditions, limitations and/or exclusions stated herein.This Rider forms a part of the Policy or Evidence of Coverage to which it is attached.
ELIGIBILITY
The following are Covered Persons under this Plan:
• Enrollee.
• The legal spouse of Enrollee.
• Any unmarried child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption
with the Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
Unmarried dependent children are covered up to age 19 or to age 23 if full-time students.
A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self-sustaining employment
because of inental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
See Schedule below for Plan Benefits, payments and/or reimbursement subject to any Copayment(s)as stated:
COPAYMENT
A Copayment amount of 550.00 shall be payable by the Covered Person at the time services are rendered.
The Copayment shall be required for professional services related to the fitting of hard contact lenses, soft contact lenses, multifocal contact lenses
or e�ended wear(firm or soft)contact lenses.
BECAUSE OF THE UNIQUE NATURE OF FITTING CONTACT LENSES, EXPERIENCE HAS SHOWN THAT THERE MUST BE SUBSTANTIAL
PATIENT MOTIVATION. THERE IS ALSO SIGNIFICANT TIME INVOLVED ON THE DOCTOR'S PART WHETHER OR NOT THE PROCEDURE IS
SUCCESSFUL. FOR THESE REASONS,THE COPAYMENT IS NOT REFUNDABLE TO THE COVERED PERSON IN ANY CASE.
PLAN BENEFlTS
Persons covered under this additional benefit are entitled to contact lenses that are referred to by VSP as "Covered,"as opposed to those that are
detined as"Necessary"or"Elective."
MATERIALS MEMBER DOCTOR BENEFIT FREQUENCY
Contact lenses Covered in full,up to a one-year supply` Available once every 12 months'"
Contact Lenses,once fumished under this plan,can only be replaced with prior authorization from VSP.
'Less any applicable Copayment
"Be innin with the first date of service.
- 11 -
Covered Persons may receive professional seNices and the contact lenses associated therewith from a Member poctor, if, in the opinion of the
Member poctor, the patient can successfully wear contact lenses.This Plan covers the initial fitting period of up to 90 days. This may be extended at
the discretion of the doctor. THIS BENEFIT DOES NOT AFFECT, NOR IS IT AFFECTED BY, THE COVERED PERSON'S ELIGIBILITY FOR
SPECTACLE LENSES AND FRAMES UNDER ANY OTHER VSP PLAN.
EXCLUSIONS AND LIMITATIONS OF BENEFlTS
NOT COVERED
There are no benefits for professional services or materials connected with:
• Orthokeratology(a procedure using contact lenses to change the shape of the comea in order to reduce myopia).
• Replacement of lost or damaged lenses.
• Modifications of lenses.
• Artistically painted lenses.
• Routine maintenance such as polishing or cleaning.
• Refitting (change in lens design)after the initial fitting.
• Services and/or materials not indicated on this Rider as covered Plan Benefits.
SERVICES FROM OUT-OF-NETWORK PROVIDERS
LIABILITY OF COVERED PERSONS FOR PAYMENT
REIMBURSEMENT PROVISIONS
When a Covered Person chooses to receive services from an Out-of-Network Provider, services may be secured from any optometrist,
ophthalmologist and/or dispensing optician. This Plan then becomes an indemnity plan reimbursing according to a schedule of allowances. The
Covered Person should pay the Provider's fee in full.VSP will reimburse the Covered Person in accordance with the following schedule.
THERE IS NO ASSURANCE THAT 7HE AMOUNT REIMBURSED WILL BE SUFFICIENT TO PAY THE MATERIALS IN FULL.
AVAILABILITY OF SERVICES UNDER THIS REIMBURSEMENT SCHEDULE IS SUBJECT TO THE SAME TIME LIMITS AND COPAYMENT AS
THOSE DESCRIBED FOR MEMBER DOCTORS. SERVICES OBTAINED FROM OUT-OF-NETWORK PROVIDERS ARE IN LIEU OF SERVICES
FROM A MEMBER DOCTOR.
VSP IS UNABLE TO REQUIRE OUT-OF-NETWORK PROVIDERS TO ADHERE TO VSP'S QUALITY STANDARDS.
SCHEDULE OF ALLOWANCES-OUT-0E-NETWORK PROVIDERS
PLAN BENEFITS
MATERIALS OUT-OF-NETWORK PROVIDER BENEFlT FREQUENCY
Extended-wear,disposable or daily Up to 5250.00' Available once each 12 months"
disposable contact lenses
`Less any applicable Copayment
"Be innin with the first date of service.
- 12-
- 13-
v�
�
CONTINUATION COVERAGE UNDER CAL-COBRA
If you are covered under a group policy providing coverage to 2 to 19 eligible employees, you may be eligible to purchase continuetl coverage under
this group vision plan under California Health and Safety Code Section 1366.20 et seq. (Cal-COBRA).
You may qualify for Cal-COBRA continuation coverage if you lose coverage for one of the following reasons:
a) The death of the covered employee.
b) The termination of employment or reduction in hours of the covered employee's employment, except that termination for gross misconduct
does not constitute a qualifying event.
c) The divorce or legal separation of the covered employee from the covered employee's spouse.
d) The loss of dependent status by a dependent enrolled in the group benefit plan.
e) With respect to a covered dependent only, the covered employee's entitlement to benefits under Title XVIII of the United States Social
Security Act(Medicare).
As a condition of receiving benefits, you must notify VSP within 60 days of the loss of coverage for one of the foregoing reasons. FAILURE TO
NOTIFY VSP WITHIN THE REQUIRED 60 DAY PERIOD WILL DISQUALIFY YOU FROM RECEIVING CONTINUATION COVERAGE.
You must request the continuation in writing and deliver the written request to VSP by first class mail or other reliable means of delivery within the 60
day period following the later of(1)the date your coverage under the group benefit plan terminated or will terminate by reason of a qualifying reason,
or(2)the date you were sent notice from the group benefit plan or VSP of eligibility to continue coverage under Cal-COBRA.
In order to continue receiving coverage under this plan, you are responsible for making all of the required premium payments in accordance with the
terms and conditions of the plan contract. The first premium payment must be made to VSP by first-class mail,certified mail or other reliable means
of delivery including personal delivery, express mail, or private courier within 45 days of the date you provided written notice to VSP of your election
of continuation of benefits. The first premium payment must equal an amount sufficient to pay any required premiums and all premiums due. Failure
to submit the correct premium amount within the 45 day period will disqualify you from receiving continuation coverage.
Notice: If the contract between VSP and the employer is terminated prior to the date your continuation coverage would terrninate pursuant to the
Cal-COBRA statute, you may elect continuation coverage under the employer's subsequent group benefit plan, if any, for the balance of the period
you would have remainetl covered under this plan. However, continuation coverage shall terminate if you fail to comply with the requirements
pertaining to enrollment in and payment of premiums to the new benefit plan within 30 days of receiving notice of termination of the prior group
benefit plan.
All notices to VSP must be sent to:
VISION SERVICE PLAN
Attn: COBRA Administration
3333 Quality Drive
Rancho Cordova, CA 95670
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