HomeMy WebLinkAboutC32510 - Vision Service Plan - 2010 Health Care Reform Contract No. C32510
CITY OF PALM DESERT f
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HUMAN RESOURCES DEPARTMENT
STAFF REPORT
REQUEST: Request for approval of Amendment No. 1 to Vision Service Plan
agreement to be in compliance with the Affordable Care Act (2010
Health Care Reform) by providing coverage to dependants up to
age 26.
SUBMITTED BY: Lori Carney, Human Resources Manager
CASE NOS. N/A
DATE: January 14, 2013
CONTENTS: Staff Report
Vision Service Plan Agreement .
Amendment No. 1 to agreement
Recommendation: �
By Minute Motion authorize Mayor to approve Amendment No. 1 to the
agreement with Vision Service Plan, providing dependant coverage up to age 26.
Backqround:
The Patient Protection and Affordable Care Act was enacted on March 23, 2010, by the
Federal Government. It contains a number of provisions which became and become
effective over the course of several years — being fully effective in 2014. One of the
provisions is that group health insurance plans that offer dependent coverage allow
dependants to remain on their parents plan up to age 26.
Vision Service Plan is amending our agreement for vision insurance services to reflect
concordance with this provision. Employee dependants covered under their parents
health and vision plans will be allowed to remain on the plan through age 26.
Contraet No. C32510
Staff Report
Vision Service Plan Agreement Amendment No. 1
January 24, 2013
Page 2 of 2
There is no increase in the premiums for this plan year. Our contract agreement expires
June 30, 2014.
Fiscal Analvsis
No increase in cost per employee, the current contract funds are available in the FY
2012/2013 budget.
Submitted by:
Lori Carney,
Human Resources Manager
Approval:
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oh�n Wohlmuth, Pa Gibson,
`Ci Manager Finance Director
CITY COUNCIL ACTION
APPROVED- , ✓ 1)t?N[F.D
RECEIVED OTHCR
MEETI�GDATE � - ��- a� l �
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ABSENT: S
ABSTAIN:
VERIFIED BY: �
Original on File with City Clcrk's O ice
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' Vlsion cere for flfe
VISION SERVICE PLAN
PLEASE ATTACH TO Y�UR
GROUP VISiON CARE PLAN
AMENDMENT TO GROUP VISION CARE PLAN
To be attached to and made part of Gxoup Vision Care Plan Number 04408001, issued to CTTY
OF PALM DESERT.
EXCEPT as specifically amended herein, said Plan shall remain in full force and effect.
TT IS HEREBY AGREED that effective January 1,2013,the Group Vision Care Plan shall be
amended as indicated below.
Section 6.01(b) shall be revised as follows:
6.41 {b) Eli�ible Denendent: If dependent coverage is provided,the persons
eligible foz coverage as dependents shail include:
(1} the legal spouse of any Enxollee,and �
;
(2) any child of an Enrollee,including any natural child from i
the moment of birth,legally adopted child from the mo�nent of placernent in the residence of the I
Enrollee,or other child for whom a court holds the Enrollee responsible; and who has not yet
attained the age of 26 years, or
� (3) as fiufher defined by Group.
08/30/2012 jah VSP/AMENDAGE.DOC ������ ����
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AU9USf 3a,2Q�2 Visfon care for life
Kristin Yokoyama
WELLS FARGO OF CALIFORNIA
21250 Hawthorns Blvd Ste 600
Torrance,CA 90503-5519 -
RE: CITY OF PALM DESERT,GROUP#00408001,
JANUARY 1,2013 DOCUMENTS
Attention Kristin Yokoyama:
Enclosed are the JANUARY 1, 2013 documer�ts for CITY OF PALM DESERT.
Please retain a copy af the documents for your�ecards and forward the additional copy direcfiy to the �I
client. I
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If you have any questions,or need additional information,please do not hesitate to contact us at 800-216-
62A�8, and a VSP representative wi{I assist you.
Enciosures
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These documents are intended onty for the cJient fo whom they are addressed and may contarn con5denfial informatron.!f you are nof fhe
intended recipient(or the person responsrble ior delivering it to the intended recipienf)and have received fhese documents in error,please
notify the sender immedisfely by felephone,and destroy or delefe fhese documenfs.
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3333 QuaUry Drive, Rancho Cordova,CA 95670-7985 � >:800.852,7600 � vsp.com �
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Visan Care for Life
VISION SERV{CE PLAN
3333 QUALITY DRIVE
RANCHO CORDOVA, GALlFORNIA 95670
GROUP VISION CARE PLAN
Group Name CITY OF PALM DESERT
Plan Number 00408Q01
State af De(ivery CALIFORNIA
Effective Date JULY 1,2012
Pian Term TWENTY-FOUR(2A�)MONTHS
Premium Due Date FIRST DAY OF MONTH
In consideration of the statements and agreements contained in the Group Application and in consideration of ;
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payment by the Group of the premiums as herein provided, VISION SERVICE PLAN ("VSPN) agrees to provide certain '
individuals under this Group Vision Care Plan ("Plan°)tl�e bertefits provided herein,subjecf to the exceptions, Iimitafions and '
exclusions hereinafter set forth. This Plan is delivered in and govemed by the laws of the state of defivery and is subject to ;
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the terms and condi�orts recited on the subsequent pages hereof, including any Exhibits or state-specific Addenda, which
are a part of this Pfan. .
James .McGrann, Pres , SP Vision Care
E
VSP-PLAN-5�07 07/17I92 Jxj �
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VISION SERVICE PLAN
GROUP VISION CARE PLAN
TABLE OF CONTENTS
I. DEFINITIONS.............................................................................................................. 1
I!. TERM,TERMINATION,AND RENEWAL................................................................... 3
III. OBLIGATIONS OF VSP.............................................................................................. 4
IV. OBLIGATl�NS OF THE GROUP................................................................................ . 6
V. OBLIGATIONS OF COVERED PERSONS UiVDER TH�PLAN............................. 8
VI. ELIGIBILITY FOR COVERAGE................................................................................... 11
VII. CONTINUATION OF COVERAGE.............................................................................. 14
VIII. ARBITRATION OF DISPUTES.................................................................................... 15
IX. NOTICES....................................................................................................................: 16
X. MISCELLANEOUS...................................................................................................... 17
EXHIBIT A
SCHEQUI.E OF BENEFITS........................................................................... 19 {
EXHIBIT B
SCHEDULE OF PREMIUMS......................................................................... 24
ADDENDUM
ADDlTIONAL BENEFIT-COVERED CONTACT LENSES........................... 25
ADDENDUM '
FOR THE STATE OF CALIFORNIA...................................................................... 27
I.
DEFlNITIONS
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Key terms used in this Plan are defined:
1.01. BENEFIT AUrFIORIZATION: Authorization from VSP itlentifying the individual nametl a Covered Person
of VSP, antl idenfifying those P�an Benefits to which Covered Person is entitled.
1.02. CONFIDENTIAI. MATTER: All confidential information concerning the med'+cal, personal, financial or
business affairs of Covered Persons obtained while providing Plan Benefits hereunder.
1.03. COPAYMENTS: Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits
which are not fully covered.
1.04. COV�RED PERSON; An�nrollee or Eligible Dependent who meets VSP's eligibility criteria and on whose
behalf Premiurns have been paitl to 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 e(igibility
established by Group and approved by VSP in Article VI of this Plan under which such Enrollee is covered.
1.06. ENiERGENCY CONDITION: A candition, with sudden onset and acute symptoms, that requires the
Covered Person to obtain immediate medica(care,or an unforeseen occurrence caAing far immediate, non-medical action.
1.07. ENROL�.EE: An employee or member of Group who meets the criteria for eligibility specified under Ar�cle
VI. ELIGIBILITY FOR COVERAGE.
9.08. EXPERIMENTAL NATURE: Procedure or lens that is not used universally ar accepted by the vision care
pmfession, as determined by VSP. -�
1.09. GROUP: An employer or other entity which cantracts with VSP far coverage under this Plan in order to I
provide wsion care coverage to its Enrollees and their Eligible Dependents.
9.10. GROUP APPLICATION: The form signed by an authorized representative of the Group to signify the I
Group's intention to have its Enrollees and fheir Eligible Dependents become Govered Persons of VSP.
1.11. GROUP VISION CARE PLAN (atso. "TFfE PLAN"l: The Plan issued by VSP to a Group, under which its
Enrollees or members, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan
Benefits in accordance with the terms of such Plan.
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1.12, MEMBER DOCTOR: An optometrist or ophthafmologist lic�nsed and otherwise qualified to practice vision �
care andlor provide visian care materi�s who has contracted with VSP to provide vision care services andlor vision care
materiais on behalf of Covered Persons of VSP.
1.13. NON-MEMBER PROVIDER: Any optome�ist, op�ician, ophthalmologist, or other licensed and qualified
vision care provider who has not contracted with VSP to provide vision care services andlor vision care materials to
Covered Persons of VSP.
1,14. PLAN BEIVEFI7S: The vision care services and vision care materials which a Covered Person is en6tled
to receive by virtue of coverage under this Plan, as defined in the Schedule of Benefits attached hereto as Exhibit A.
1.15. RENEWAL DATE: The date when the Plan shall renew,or terminate if proper notice is given.
1.16. SCHEDULE OF BENEFITS: The document, attached hereto as Exhibit A to this Plan,which fists tt�e vision
care services and vision care materials which a Covered Person is entitled to receive 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 behalf of a Covered Person to entitle himlher to Pfan Benefits.
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TERM,TERMtNATION,AND RENEWAL
2.01. Plan Term: This Plan is effective on the EfFective Date and shall remain in effect for the Plan Term. At the
end of the Plan Term, the Plan shall renew on a month to month basis unless either party notifies the other in writing, at
least si�cty (6Q}days before the end of the Plan Term fhaf such party is unwilling to renew the Pian. If such nofice is given,
the Plan shall terminate at 11:59 p.m.on the last day of the Plan Term unless the parties agree on its renewat 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 notice to the other party.
If VSP issues written renewal materials to Group at least sixty(60j days before the end of the Plan Term and Group
fails to accept the new terms andlor rates in wri#ing prior to the end of the Plan Term,this Plan shall terminate at 91:59 p.m.
on the last day of the Plan Term.
2.02. Eariy Termination Provision: The Premium rate payable by Group to VSP under fhis Plan is based on an
assumption that VSP will receive these amounts over the full P(an Term in order to cover costs associated with greater
vision utilization that tends to occur tluring the first par�ion of a Plan Term. If Grou terminates this Plan before the entl of 4
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the Plan Term or before the enQ of any subsequent renewal terms, for any reason other than material breach by VSP,
Group will remain liable to VSP for the less�r amount of any deficit incurr�d by VSP or the payments which Group would
have paid for the remaining term of this Plan, not to exceed one year. A deficit incurred by VSP will be calculated by
subtracting the cost of ir�urred and outstanding claims, as calculated on an incurred date basis with a claim run-out not to
exceed six months from the date of termination, from the net premiums received by VSP from Group. Net premiums shall
mean premiums paid by Group minus any applicable retention amoun#s and/or broker commissians. Group agrees to pay
VSP within thirty-one(31)days of no�ficatian of the amount due.
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QBLlGATIONS OF VSP
3.01. Coverage af Covered Persons: VSP will enrol! for caveraqe each eligible Enrollee and his/her Eligible
Dependents, if dependent coverage is provided, all of who shall be referred to upon enrollment as"Covered Persons" 70
institufie coverage,VSP may require Group to complete,sign and forward to VSP a Group App(ication along with information
reyartling Enrollees and Eligible Dependents, and aff applicable premiums. (�efer to VI, ELIGIBIIlTY FOR COVERAGE
for further details.} �
Following the enrollment of the Covered Persons, VSP will provide Group with Member Benefit Summaries for
tlistribution to Cavered Persons. 5uch Member Benefit Summaries will summarize the terms and condi6ons set forth in this
Plan.
3.02. Provision of Plan Benefitg: Through its Member poctors (or through other licensetl 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 Benefifs listed in the Schedule of Benefits, Exhibit A hereto, subject to any limitations,
exclusions, or Copayments therein stated. BeneSt Authorization mus#be obtained prior to a Cavered Person obtaining Plan
Benefi#s from a Member Dactor. VIlhen a Covered Person seeks Plan Benefits from a Member poctor,the Covered Person
must schedule an appointment and identify himself as a VSP Covered Person so the Member poctor can obtain Ber�fit
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 Aut?mrization will confain an expiration date, stating a specific time period for
the Covered Person to obtain Plan Benefits. VSP shall issue Benefit Authorizations in accordance with the latest eligibility
infarmation furnished by Group and the Covered Person's past senrice utilization, if any. Any Benefit Authorization so
issued by VSP shall constitute a cefification to the Member poctor that payment will be made, irrespective of a later loss of
eligibility of the Covered Person,provided Plan Benefits are received pnor to the Benefit Authorization expiration date. !
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VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any applicable Copayment,
within a reasonable time but nof more than thirty �30} calendar days after VSP has received a campleted claim, unless
special circumstances require additional time. in such cases,VSP may obtain an extension of fi�een (15)calendar days of
this time limit by providing no#ice to the claimant of the reasons far the extension.
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3.�3. Provision of Information to Covered Persons: Upon request, VSP shall make availabfe to Covered
Persons necessary informa�an describing Plan Benefits and haw to use them. A copy of this Plan shall be placed with
Group and also wil) be made available at the o�ces of VSP for any Covered Persons. VSP shall provide.Group with an
updated list of Member poctors' names, addresses, and telephone numbers for distribution to Covered Persans fwice a
year. Covered Persons may also abtain a capy of the Memk�r pocfor directary through contacting VSP's Cusfomer Service
Deparfinent's toil-free Custamer Service telephone line,VSP's V11eb site at www,vsp.com,ar by wrftten request.
3.�4. Preservation of Con�identialitv; VSP shall hold in strict confidence all Confidential Matters and exercise
its best efforts to prevent any of its employees, Member poctors,or agents,from disclosing any Confidential Matter, except
to the extent that such disclosure is necessary to enable any of the above to perform their obligations under this Plan,
including but not limited to sharing information with rr�dEcal informafiian bureaus, or complying with applicable 1aw. Covered
Persons and/or Groups that want mare information on VSP's Confidentiality paficy may obtain a copy of the policy by
contacting VSP's Customer Service pepartment or VSP's Web site at www.vsp.com.
3.05. Emergency Vision Care: When vision care is necessary for Emergency Canditions, Covered Persons
may obtain Plan Benefits by contact+ng a Member poctor or Non-Member Provider. No prior approval from VSP is required
for Covered Person to abtain vision care for Emergency Contlitions of a medical na#ure. However; services for medical
conditions, including emergencies, are covered by VSP anly under the Acute �yeCare and Supplemental Primary EyeCare
Pians. If Group has not purchased one of these pfans, Cavered Persons are not covered by VSP for medical services and
should contact a physician under Covered Persons' 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 C�stomer Service
Depar#ment for assisfance. Reimbursement and e(igibifity are subject to the terms of this Plan.
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�V.
08LtGATiONS OF THE GROUP .
4.01. tderrti#ication of Eli�ible Enrotlees: An Enrollee is eiigibie for coverage under this Pian if he/she satisf�s
the enrollment criteria specified in Paragraph 6.01(a) and/or as mutuafly agreed to by VSP and Group. By the E�ective
Date of this Plan, Group shall provide VSP with eligibility informa�on, in a mutually agreed upon format and medium, to
identify afl Enrollees who are eligible for caverage under this Plan as of that date. Therea�er, Group shall supply to VSP by
the last day of each month, eligibility information sufficient to identify alI Enrollees to be added fo or deleted from VSP's
coverage rosters for the next month. The eligibifity information shall include designation of each Enrollee's family status if
dependent coverage is provided. Upon VSP's requesf, Group shall make avaiiable for inspection records regarding the
coverage of Covered Persons untler this Plan.
4.02. Payment of Premiums: By the last day of each month, Group shall remif to VSP the premiums payable for
the next month on behalf of each Enrollee and Eligibfe Dependents, if any,to be covered under this Plan. The Schedule of
Premiums incorparated in fhis Plan as Exhibit B provides the premium amount for each Covered Person. Only Covered
Persons for whom premiums are actually received by VSP shall be entitled to Plan 8eneflts under this Pfan and only for fhe
period for which such payment is received, subject to the grace period provision below. If payment for any Covered Person
is not received on fime, VSP may terminate all righ�s of such Covered Person. Such rights may be reinstatetl 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
Benefits or there is a material change in Plan terms or conditions, provided any such change is mutually agreed upon in
wrifing by VSP and Group.
Notwithstanding the above, VSP may increase premiums during a Plan 7erm by the amount of any tax or
assessment not now in effect but subsequently levied by any taxing authority, which is attributable to premiums VSP
received from Group. .
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4.03. Grace Period: Group shall be allowed a grace period of thirty-one (31) days following the premium
payment due date to pay premiums due under this Plan. During said grace period, this Plan shall remain in full force and
effect for all Cover�d Persons of Group. VSP will consider late payments at the time of Plan renewal. Such payment may
impact Graup's premium rates in future Plan Terms.
If Group fails ta make any premiums payment due by the end of any grace period, VSP may notify Graup that the
premiums payment has not been made, that coverage is cancelsd and that Group is responsible for payment for all Plan
Bene�ts provided to Covered Persons after the last periad for which premiums were paid in full, including the grace period
through the effective dafe of termination. Group shall also be responsible for any legal andlor coflection fees incurred by
VSP to coliect amounts due under this Plan.
4.04. Distribution of Required Documents: Group shall distribute to Enroflees any disclosure forms, plan
summaries or other material required to be given to plan subscribers by any regulatory authority. Such maferials shall be
distributed by Group no later than thirty(30)days after the receipt thereof,ar as required under state law.
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V.
�BLIGATI�NS OF COVERED PERSONS UNDER THE PI.AN
5.01. Genera: By this Plan, Group makes coverage available to i�s Enrollees and their E(igible Dependen�st if
dependent caverage is provided. However, this Plan may be amended or terminated by agreement between VSP and
Group as indicated herein,withou#the consent or concurrence of Covered Persons. This Plan, and �{ Exhibits, Riders and
attachments hereto,constitute VSP's sole and entire undertaking to Covered Persons under this Plan.
As canditions of coverage,all Covered Persons under this Plan have the fo[lowing obligations:
5.02. GQ�yment for Services Receiv�d: Where, as indicated in Exhibit A(Schedule of Benefits), Copayments
are required for certain Plan Benefits, Copayments shall be the personal responsibilify of the Covered Person receiving the
care and must be paid to the Member poctor the date services are rendered.
5.U3. Obtaining Services from Member po�ors: Beneft Authorization must be obtained prior to receiving Plan
Benefi�s from a Member poctor. When a Covered Person seeks Plan Benefits,the Covered Person must select a Member
Doctor, scheduie 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 Benefit
Authorization, then for the purposes of tho�e Plan Benefits provided to the Covered Person, the Member poctoc wilf be
considered�a Non-Member Provider and the benefits available will be limited to those for a Non-Member Provider,if any.
5.Q4. Submission of Non-M�nber Provider Claims: If Non-Member Provider coverage is indicated in Exhibit
A(Schedule of Benefits),written praof(receipt and the Covered Person's identification information)of all claims for services
received from Non-Member Providers shai! be submitted by Covered Persons to VSP within three hundred sixty-five (365)
days of the date of service. VSP may reject such cfaims filed more than three hundred sixty-five(365)days after the date of
service.
Failure to submit a claim within this time period, however, shafl not invalida#e or reduce the claim if it was not
reasonably possible to submif the claim within such 6me period, provided the claim was submitted as soon as reasonably
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possible and in no event, except in absence of legal capacity, later than one year from the required dafe of three hundred �
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sixty-five(365}days a�er the dafe of service. �
5.05. Complaints and Grievances: Covered Persons shall reporf any complain�s and/or grievances to VSP at �
the address given herein. Complaints and grievances are disagreernents regarding access to care, quality of care,
treatment or service. Gomplaints and grievances may be submifted to VSP verbally or in writing. A Covered Person may
submit written comments or supporting documentatian concerning his camplaint or grievance to assist in VSP's review.
VSP will resolve the complaint or grievance within thirty�30)days after receipt .
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5.06. C1aim Denial�aeais: If, under the terms of fhis Plan, a claim is denied in whole or in part,a request may
be submiited to VSP by Covered Person or Covered Person's authorized representative for a full review of the denial.
Coveretl Person may designate any person, including hislher provider, as his/her authorized representative. References in
this section to"Covered Person"include Covered Person's aufhorized representative,where applicable.
a) Initial AppeaE: The request must be made within one hundred eighty (180� days following denial
of a claim and should contain su�cient information to identify the Govered Person for whom the claim was denied, including
the VSP Enrollee's name, the VSP Enrollee's Member ldentification Number, the Covered Person's name and date of birth,
the provider of services and the claim number. The Cavered Persan may review, during normal worlcing hours, any
documents held by VSP pertinent to the denial. The Covered Person may also submit written commenks or supporting
documen#afion concerning the claim to assist in VSP's review. VSP's determination, including specific reasons for the
decisian, shall be provitled and communicated to the Covered Person within thirty (34) calendar days after receipt of a
request for appeal from the Covered Person or Covered Person's authorized representative.
b) Second Leve(Appeal: lf the Coveretl Person disagrees with the response to the initial appeaf of
the claim, the Covered Person has a right to a second level appeal. Within sixty (60) calendar days after receip#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 fhe Covered Person in compliance with a(I appficable
state and federa!laws and regulations and shall include the specific reasans for the dekermination. �
cJ Other Remedies: When Covered Person has completed fhe appeals process stated herein,
addifional voluntary aftemative dispute resolution aptions may be available, including mediation, or Group shouid advise
Covered Person to contacf the U.S. Deparfinent of Labor or the sfiate insurance regulatory agency for details. Additionally,
under tF�e provisions of ERISA(Section 502(a)(1}(B)) (29 U.S.C. 1132(a�(I)(B)j, Covered Person has#he�ight 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.
5.07. Time of Ac#ion: No action in !aw or in equity shall be brought to recaver on the Plan prior to fhe Covered
Person exhausting his/her grievance rights under this Plan and/or prior to the expiration of sixty (60) days after the claim
and any applicable invoices have been filed with VSP. No such action shall be brought after the expirafion of six (6) years
from the last date that the claim and any applicable invoices were submitted to VSP, in accordance with the ferms af this
Pfan.
5.08. Insurance Fraud: Any Group and/or person who intends to defraud, knowingly facilitates a fraud or
submits an applicatian or flles a claim with a fafse or deceptive statement, is gui(ty of insurance fraud. Such an act is
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grounds for immediate termination of the Pian for the Group or individual that committed the fraud.
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VI.
ELIGIBiL1TY FOR COVERAGE
6.01. Eligihility Cr�teria: Individuals wiil be accepted for coverage hereunder only upon meeting all the
applicable requirements set forth below.
{a) Enrollees: To be eligible for coverage, a person must
(1)currently be an employee or member of the Group, and �
(2}meet the criteria establishetl in the coverage criteria mutually agreed upon by Group and VSP.
(b) Eligible Dependents: If dependent coverage is provided, the persons eligible for dependent
cvverage are:
(1)the legaf spouse of any Enrollee,and
(2)any unmarried child of an Enrallee, including any natural child from the momenf of bir#h, legally
adopted child from t�e morr�ent of pfacement for adoption with the Enrollee, or other chiid for whom a court holds the
Enrallee responsib(e;and
�A� for whose support the Enroilee is legally responsible and who has not yet attained the
age of 19 years,or
(B) who is chiefly tlependent upon the Enrollee for support, has not yet attainetl the age of
23 years, and is currently enralled as a full-tirne student in goad standing actively pursuing a degree or certificate at a
recognized educational institution.
(3� as further defined by Group.
!f a dependent, unmarried child prior to attainment of the prescri�ed age for termination of eligibility becomes, and
continues to be, incapable of self-sustaining employment because of inental or physical disability, that Eiigible DependenYs
coverage shalE nof terminate so lang as he remains chiefly dependent on the Enrollee for support and the Enrollee's
coverage remains in force; PROVIDED that satisfactory proof of the dependen#'s incapacity can be furnished to USP within
thirty-one (31) days of the date the Eligible Dependent's coverage would have otherwise terminated or at such other times
as VSP may request proof, but not more frequently than annualiy.
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6.02. Dacumentation of Eligibifitv: Persons satisfying the coverage requirements under either of the above
criteria shaf!be eligible if:
(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 above,VSP may elect to audit Group's records in order to verify
eligibiiity of Enrollees and dependents and any errors. Subject to the terms of Paragraph 4.03 abave, only persons on
whose behalf premiums have been paid for the current period shall be en6tled to plan Benefits hereunder. lf a clericaf error
is made,it will not affect the coverage a Covered Person is enfitled under the Plan. �
6.03. Retroactive Eligibilit�Changes: 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 retroac6ve termina#ion of a Covered
Person if Plan Benefits have been obtained by, or authorized for, the Covered Person after the effective date of the
requested termination.
6A4. Change of Participation Requirements Contribution of Fees, and Eliaibilitv Rules: Cor�osition of
the Group, percentage of Enrotlees covered under the Plan, and Group's cantribution and eligibility requirements, are all `
material to VSP's obligations under this Plan. During the term of this Pfan, Group must provide VSP with written notice of �
changes to its composition, percentage of Enrollees covered, con�ibution and eligibility requirements. Any change which I
materialiy affects VSP's obligatians under this Plan must be agreed upon in writing befween VSP and Group and may �
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constitute a material change to the terms and condi6ons of this Plan for purposes of Paragraph 4.02. Nothing in this section (
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shafl limit Group's ability to add Enrollees or Eligible Dependents under the terms of this Plan. j
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6.�5. Change in Family Status: In the event Group is notified of any change in a Covered Person's family
status [by marriage, the addition(e.g., newborn or adopted child}or deletion of Dependent, etc.J Group shall provide notice
of such change f� VSP via the next eligibifity listing required under Paragraph 4.01. If notice is given, the change in the
Covered Person's status wil! be effective on the first day of the manth following the change request, or at such later date as
may be requested by or on behalf of the Covered Person. Notwi�hstanding any other provision in tf�is section, a newborn
chi[d wi(E be covered during the thirty-one (31� day period after birth, and an adopted child will be covered for the thirty-one
(31) day period after the date the Enrollee or Enroflee's spouse acquires the right to control that chiEd's health care. To
continue coverage for a newborn or adopted child beyond the initial thirty-one (31) tlay period, the Group must be properly
notified of the EnroQee's change in family status and applicable premiums must be paid ta VSP.
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v�i.
CONTINUATtON�F C01lERAGE
7.41. COBRA: The Consalidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under
certain circumstances, health plan benefits available to an Enrollee and his or her Efigible Dependents be made available
for purchase by said persons upon the occurrence of a COBRA qualifying event If, and only to the ext�nf, COBRA applies,
VSP shall make the statutorily-requi�ed cor�inua�on coverage available for purchase in accordance with COBRA.
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AR�I7RATtON OF DISPU7ES
8.01. Dis ute Resolution: Any dispute or question arising between VSP and Group�or any Cavered Person
involving the application, interpretation, or performance under this Plan shali be settled, if possible, by amicable antl
informal negotiations. This wil! allow such appvrtunity as may be appropriate under the circumstances for fact-fintling antl
mediafion. If any issue cannot be resoived in this fashion, it shall be submiifed ta arbitration.
8.02. Proce r : The procedure for arbitration hereunder shall be canducted pursuant to the Rules of the
American Arbitration Association.
8.03. Choice of Law: If any matfer arises in connection with this Plan which becorr�es the subject of arbifration
or legal process,the law of t�e State of Delivery of the Plan sha11 be#he appficable law.
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IX.
NOTICES .
9.01. Required Notices: Any notices required under this Plan to either Group or VSP shail be in written format.
Notices sent to Group will be sent to the address or email address shown vn the Group's Application unless othenNise
directed by the Group. Notices sent to VSP shall be sent to the address shown on the first page of this Plan.
Notuvithstanding the above, any notices may be hand-delivered by either party to an appropriate representative of the other
party. The party effecting hand-delivery bears the burden to prove tlelivery was made,if questioned.
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MISCELLANE�US �
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14.01. En ir PI n: This Plan, the Group Application, the Evidence of Caverage, antl all Exhibits, Riders and
attachments hereto, and any amendments hereto; constitute the entire agreement of the parfies and supe�sedes any prior
understandings and agreements between them, either written or oral. Any change or amendment to the Plan must be
approved by an officer of 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
I'lan.
10.02. Indemni :VSP agrees to indemnify, defend and holtl harm{ess Group, its shareholders, direc#ors,officers,
agents, employees, successors and assigns from and against any and all liability, claim, lass, injury, cause of action and
� expense (including defense cos�s and legal fees) of any nature wha#soever arising from the failure of VSP, its officers,
agents or employees, to perform any of the activities, duties or responsibilifies specifed herein. Group agrees to indemnify,
defend and hold harmless VSP, its members, shareholders, directors,officers, agents, employees, successors and assigns
from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal �
fees)of any nature whatsoever arismg or resulting from the failure of Group, its officers or employees to perform any of the I
duties or responsibilities specified herein.
10.03. Li ili : VSP arranges for the provision of vision care se�vices and materials through agreements wi#h
Member poctors. Member poctors are indepentlent contractors and responsible for exercising independent judgmenf.
VSP does not itself directly furnish vision care ser�ices or supply materials. Under no circumstances shall VSP or Group be
liable for the negligence, wrongful acts or omissions of any doctor, labarafiary, or any other person or organization i
performing services or supplying materials in connection with this PEan.
14.U4. Assignment: Nei�her this Plan nor any of the rights or obligations of either of the parfies hereto may be
assigned or transferred without the prior written consent of both parties hereto except as expressiy authorized herein.
10.05. Severabili : Should any provision of this Plan be declared invalitl, the remaining provisions shali remain
in full force and effect.
10.08. Governing Law: This Plan sha11 be gaverned by antl canstrued in accordance with applicable federal and
state law. Any provision that is in conflict with, or not in campliance with, applicable federal or state statutes or regulations
is hereby amended to conform with the requirements of such statutes or regulations, now or hereafter exis6ng.
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10.07. Gender: All pronouns used herein are deemed to refer fo fhe mascufine, feminine, neuter, singufar, or �
plural,as the identity(ies)of the person(s)may require. i
1 Q.08. Equal Opportunitv: VSP is an Equal Opportunify and Affirmative Ac6on empbyer. f
10.09. GrievancesfComplaints: The California Department of Managed Health Care is responsible for regulating �
health care service plans. If you have a gr�evance against your health plan, you should first telephone your health plan at
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(80Q) 877-7195 and use your health plan's grievance process before contacting the Qepartment. 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 invo[ving 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 tlays,you may call the Department for assistance.
The pepartment also has a toll-free telephone number (1-888-HMO-2219), a TDD line (9-877-688-9891) for the
hearing impaired and its Internet Web site (http://www.hmahelp.ca.gov) has complaint forms online. The plan's grievance �
process and the Department's complaint review process are 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 Cavered Person's use of any
other remedy provided by law.
10.10. Communication Mate�als: Communication materials created 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 be 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 nat encompass or constitute certification that Group's materials meet any
appiicable legal or regulatory requiremenfs,including but not limited to, ERISA requirements.
18
�XHIBIT A.
VISION SERVICE PLAN
SCNEDULE�F BEN�FITS
Signature Pian
GENEi2AL
This Schedule lists the vision care services and vision care ma#erials to which Cover�d Persons of VSP are entitled,subject
to any Copayments and ather canditians, limitations and/or exdusions sta�ed 1�rein. If Pfan Benefifs are available for
Nan-Member Provider services, as indicated by the reimbursement provisions below, vision care seruic�s and vision care
materials may be received from any ficensed optometrist, ophthalmologist, or dispensing optician, whether Member pocto�s
or Non-Member Providers. This Schedufe forms a part of the Plan or Policy to whieh it is attachetl.
When Plan Beneflts are received from Member poctors, benefits appearing in the first co(umn below are applicable subject
to any Copayments as stated below. When Plan 8enefits are avaiiable and received from Non-Member Providers, the
Covered Person is reimbursed for such benefits according to the schedule in the second column be(ow less any applicable
Copayments.
COPAYMENT
The benefits described hecein are available to each Covered Person subject only to payment of the applicable Copayment
by the Covered Person. Copayments are required for Plan Benefits received from Member poctors and Non-Member
Providers. Cavered Persons must also follow the proper procedures for obtaining Benefit Authorizatian.
A Copayment amount of$10.00 shall be payable by the Covered Person to the Member poctar at the 6me services are
rendered.
PLAN BENEFITS
MEMSER DOCTOR NON-MEMBER
BENEFIT PRQVIDfR BENEFI7
VISION CARE SERVICES
Eye Examinatian Covered in Full* Up to$ 50.00*
Comp[ete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of
corrective eyewear where indicated.
Subsequent regular eye examinations every 92 months.
*Less any applicable Copayment.
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VISION CARE AAATERIALS
MEMBER DOCTOR NON-MEMBER
BENEFIT PRQVIDER BENEFiT
Lenses
Single Vision Covered in full" Up to$ 50,00*
Sifocai - Covered in full* Up to$ 75.00*
Trifocal Covered in fullY Up to$ 100.�*
Lenticular Covered in fuli* Up to$ 125.00*
Available once every 12 months.
Frames Covered up to Plan Up to$ 70.OQ"
Allowance*
Available once every 24 months.
*Cess any applicable Copayment �
Frame allowance may be applied towards non-prescripfion sunglasses for post PRK,LASIK,or Custom LASIK patients.
Lenses and frames include such prafessional services as are necessary,which shall include:
• Prescribing and ordering proper lenses;
• Assis�ng in the selection of frames;
� Verifying the acc�acy of the finished lenses;
• Proper fi#ting and adjustment of frames;
• Subsequent adjustments to frames to maintain comfort and e�ciency;
• Progress or follaw-up work as necessary.
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CON7ACT LENSES
Con�act (enses are available once every 12 months in lieu of all other lens and frame benefits available herein. When
eontact lenses are obtained,the Covered Person shall nof be eligible for lenses and frames again for 12 months.
Necessary-
Necessary Contact Lenses are a Plan Benefi#when specifc benefit criteria are satisfied and when prescribed by Coveretl
Person's Member poctor or Non-Member Provider. Prior review and approval by VSP are not required for Coveretl Person
to be eligible for Necessary Confact Lenses.
MEMBER DOCTOR NON-MEMBER
BEN�FIT PROVIDER BENEFIT
Professional Fees and Materials � Professional Fees and Materials
Covered in full* Up to$210.00*
Elective-
MEMBfR DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Elective Contact Lens fitting antl
evalua�ion*"services are covered in full
once every 12 months,affer a maximum
$60.00 Gopayment.
Materials Professional Fees and Materials
Up to$130.00 Up to$105A0
*Subject to Copayment
**15°Io discount applies to Member poctor's usual and customary professional fees for contact lens evaluation and fifting. (
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LOW VISION BEPIEFIT
The Low Vision benef�t is avaifable to Covered Persons who have severe visual problems that are not correctable with
regular lenses.
MEMBER DOC70R NON-MEMBER
EB NEFIT PR01/fDER BENEFtT
Supplementary Testing Covered in Full Up to$125.00 .
Complete low vision analysisldiagnosis, which includes a comprehensive examination af visual funcfions, including the
prescription of corrective eyewear or vision aids where indicated.
Supplemental Care Aids 75%0 of Cast 75°/a af Cost
Subsequent low vision aids.
Copayment for Supplemental Aids: 25%payable by Govered Person.
Benefit Maximum
The maximum benefit available is$1000.Q0(excluding Copayment)every two years.
NON-MEMBER PROVIDER BENEFIT
Low Vision benefits securetl fiom a Non-Member Provider are subject to the same time limits and Copayment arrangements
as described above for a Member poctor. The Covered Person shou(d 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: There is no assurance that this amount will be within the 25%Copayment feature.
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EXCLUSlONS APlD LIMITATIONS OF BENEFI7S
Some brands of spectacle frames may be unavailab(e for purchase as Plan Benefits, or may be subjecf to additional
limitations. Govered Persans may obtain details regarding frame brand availability from their VSP Memk�r poctor or by
cafling VSP's Customer Care Div�sion at(800}877-7195.
PA7IENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When the Cavered Person seleets any of the
following extras, the Plan will pay the basic cost of the allowed lenses or frames, and fhe Covered Person will pay the
additionaf costs for the options.
• Optional cosme�c processes.
• Anti-reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
� Oversize lenses.
• PoEycarbonate lenses.
• Photochromic lenses,tinted lenses except Pink#1 and Pink#2.
• Progressive multifocal lenses.
� UV(ultraviolet)pratected lenses.
• Certain limitations on low vision care.
• A frame that costs more than the Plan allowance.
• Contact lenses(except as noted elsewhere herein).
N07 GOVERED
There is no benefit for professiona(services or materials connected with:
• Orthoptics or vision training and any associated supplemental#esting; plano lenses(less than a t .50 diopter power}; or
two pair of glasses in lieu of bifocals,
• Replacement of lenses and frames furnished under this Plan which are los�or broken, except at the normal intervals
when services are otherwise avaifable;
• Medical or surgical treatment of the eyes;
• CoRec6ve vision tr�atment of an Experimental Nature;
• Costs for services andlor mat�rials above Plan Benefit allowances;
• Services andlor materials not indicated on this Schedule as covered Plart Benefits.
VSP MAY, AT ITS DISCRETION, WAIVE Af�Y OF THE PLAN LIMITATIONS IF, IN THE OPINION OF VSP's
OPTOMETRlC CONSUITANTS, IT IS NECESSARY FOR THE VISUAL WELFARE 4F THE C4VERED PERSON.
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EXHIBIT B .
VISION SERVICE PLAN
SCHEDULE OF PRERflIUMS
Signature Plan
VSP sha[( be entitled to receive premiums for each month on hehalf of each Fnrollee and hislher Elig9ble Dependen#s, if
any,in the amounts specifred below:
$ 29.41 per month for each eiigible Enrolfee(indudes coverage for Eligible Dependents)
NOTICE: The premium under this Plan is subject�o change upon renewal (after the end of the lnitial Plan Term or any
subsequent Plan Term),or upon change of the Schedule of Beneffs or a material change in any other terms or conditions of
the Plan.
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AQDENDUM
VISION SfRVICE PLAfV
ADDITIONAL BENEFIT•COVER�Q C4NTACT LEIdSES
BENEFITS
Persons covered under this additional benefit are entitletl to contact lenses which are referred to by VSP as "covered" as
opposed to those which are defined as"Necessary"under the standard coverage.
A Cavered Persons may receive professional services and the contact lenses associated therewith from a Member
Doctor, if in the apinian of the Member poctor the patient can successfulfy wear contact lenses. This Plan covers
the initial fi�ing period of up to 90 days. This may be extended at the discretion of the doctor. THIS BENEFIT
DOES NOT AFFECT, NOR IS IT A��ECTED BY, THE COVERED PER50N'S ELIGIBILITY FOR SPECTACLE
LENSES AND FRAMES UNDER THE REGULAR PLAN.
B For each Covered Person seeking services under this benefrt,there shall be a Copayment as folfaws:
TYPE Q�LENS FfTTING AMOUNT OF COPAYMENT
Disposable contact lenses, $ 50.OU
including daily disposable confact lenses
BECAUSE OF 7HE UNIQUE NATURE OF FITTING CONTACT LENSES, EXPERIENCE HAS SH01NN THAT THERE
MUST BE SUBSTANTIAI. PATIENT MOTfVAT10N. THERE IS ALSO SIGNIFICANT TIME INVOLVED ON THE
DOCTOR'S PART - WHETHER OR NOT THE PRQCEDURE IS SUCCESSFUL. FOR THESE REASONS, 7HE
COPAYMENT IS NOT REFUNDABLE TO THE COVERED PERSON IN.ANY CASE.
C UVhile the professional contact lens services received under this program is essentially prepaitl far most types of
fittings, there are certain additional features, such as artistically painted contact lenses, for which the Coveretl
Person may be required to make an additional payment.
EXCLUSIONS
The following items are not covered under this Plan: i
• Orthokeratology
• Replacement of lost or damaged lenses ,
� Modifications of lenses �
� Routine maintenance such as polishing
• Refitting (change in lens design)a�er the initial fitting �
-this wi(1 be the responsibility of the Covered Persan �
NON-MEMBER PROVIDERS
Covered contact lens services secured from a doctor who is NOT a member of the VSP panel are subject to the same time
limits and Copayments described herein. The Covered Person should pay the NonMember Pravider his full fee. Covered
Persons will be reimbursed in accordance with a schedule as shown in the Schedule of Benefits below. THERE IS NO
ASSURANCE THAT THE SCHEDULE W(LL BE SUFFICIENT TO PAY FOR THE SERVICES RECEIVED.
CONTACT LENSES, ONCE FUfiNISHED UND�R TNIS PLAN, CAN BE REPLACED ONLY WITH PRIOR
AUTHORIZATION BY VSP, BEJT IN NO EVENT MORE FREQUENTLY THAN EVERY 12 MONTHS.
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C�VERED CON7ACT LENS SCHEDULE OF BENEFITS
Covered- Covered contact lenses are provided as an additional benefit under the plan.
MEMBER DOCTOR NON-MEMBER
BENEFfT PROVIDER BENEFI7
Professional Fe�s and Materiafs Professional fees and Materials
Covered in full* Up to 5250.00�
*Subject to Copayment.
COVERED CONTACTS ARE PROVIDED UNDER THIS PLAN EVERY 12 MONTHS.
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ADDENDUM
VfS10N SERVICE PLAN
THE CALI�ORNIA C�NTINUATION BENEFITS
RERLACEAflENT ACT OF 1997(CAL-COBRA)
Pursuant to California Health and Safety Code Section 1366.25, the foliowing secfian is hereby incorporated into the Group
Vision Care Plan,if,and only fo the extent Cal-C4BRA applies to the parties to this PEan:
The California Continua�an Benefits Replacement Act of 1997 (Gal-COBRA} requires health care service plans providing
contracted coverage to employers with 2 to 19 eligible employees to affer 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 w�th continuation coverage;
1. Group agrees to provide VSP with notice of any employee who has hatl a "qualifying event", within 31 days of the
qualifying event. A�qualifying event" means any of the following events that, but for the elecbon of continuation coverage
provided thereunder,would result in a loss of coverage under fhe group benefit plan to a qualified beneficiary;
• The death of the covered emp[oyee.
• The termination or reduction of hours of the covered employee's employment, except that termination far gross
misconduct does not constitute a qualifying event.
• The divo�ce or legal separation aithe covered employee from the covered employee's spouse.
• The loss of dependent sfatus by a dependent enrolled in the group benefit plan.
• With respect to a dependent anly, the cavered employee's eligibility for coverage under Title XVIII of the United States
Social Security Act{Medicare).
Within 14 days of receipt of the faregoing nofice of a qualifying evenf from Group, VSP will send ta the qualified
beneficiary's last known address, as provided by Graup, the necessary benefits information, premium information,
enrollment farms, and instructions to allaw the qualified beneficiary to farmally elect continua6on coverage.
2. Group agrees to nofify qualified beneficiaries curren#ly receiving continuafion coverage, whose continuation
coverage wiEi terminate under one group benefit pian prior to the end of the period the qualified benefrciary would have
remained covered under Cal-C46RA, as specified in Health and Safety Code Section 1366.27,a minimum of 30 days prior
#o the termination, of the qualifietl beneficiary's ability to continue coverage under a new group benefit plan for the balance
of the period the qua(ified beneficiary would have remained covered under the prior group benefit plan. Group agrees to
provide qua�ified beneficiaries subject to this paragraph with the necessary benefits information, premium information,
enro!lment forms, and instructions to allow the qualified benef�ciary to continue caverage. This informafion shall be sent to
the qualified beneficiary's last known address, as provided by the plan currently providing continuation coverage to the I
qualified beneficiary.
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�rou Vision Care Plan
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VS �
Vision Care for Life
EVIDENCE OF COVERAGE
&
DISCLOSURE FORM
Provided by:
VISION SERVICE PLAN
3333 Quafity Drive,Rancho Cordova,CA 95670 _
(916}851-5000 (800)877-7195
THIS EVIDENCE OF COVERAGE AND DISCLOSURE FORM DISCLOSES THE TERMS AND CONDITIONS OF
COVERAGE. f�EASE REAn THE FORM C�NfPLETELY AND CAR�FULLY. INDIVIDUALS WITH SPECIAL
HEALTHCARE NEEDS SHOULD CAREFULLY READ THOSE SECTIONS THAT APPLY TO THEM. ALL APPLICANTS
HAVE A RIGHT TO REVIEW THE EV(DENCE OF COVERAGE AND DISCLOSURE FORM PRIOR TO ENROLLMENT.
cnR�sK�oaso o�n7ia2,�i
To be filied in by emplayer in the event this document is used to develop a Summary Plan Descripfion:
NAME OF EMP�OYER;
fdAME OF PLAN:
PRINCIPAL AbDRESS:
EMPLOYER I.D,#:
PLAN#: �
PLAN ADMINISTRATOR;
ADDRESS:
PHONE NUMBER:
REGISTERED AGENT FOR SERVICE OF LEGAL PROCESS, IF DIFFERENT FROM PLAN ADMINISTRATOR;
ADDRESS:
THiS �VIpENCE OF COVERAGE AND DtSCLOSURE FORM CONSTITUTES ONLY A SUMMAftY OF i'H� TEi2MS AND CONDITIONS OF
COVERAGE. THE PLAN[ CONTRACT ITSELF SHOULD BE CONSULTED TO DETERMINE GOVERNING TERMS AND CONDITIONS OF
COIfERAGE.
DEFINITIONS:
ADDITIONAl.BENEFIT The document attached to this Evidence of Coverage„ when purchased by Group,which lists selected vision
RIDER care services and vision ca�e materials that a Covered Person is enti0ed to receive by virtue of 1he Plan.
ANISOMETROPIA A condition of unequa(refracfi�e state for the Fwo eyes,one eye requiring a different isns correction than the
other.
BENEFIT AUTMORIZATION AutltorizaGan issued by VSP identiiying the individual named as a Covered Person of VSP, and identifying
those Plan Benefits to which a Covered Person is enGtled.
COPAYMENTS Any amounts require8 to be paid by or on behalf of a Covered P�son for Plan Benefifs which are not fully
covered.
COVERED PERSON An Enr�diee a Eligible Dependertt who meets VSP's eli�biliiy critsria and on ufiose beha(1 Premiums have �
been paid ta VSP,and who is covered under this plan.
ELIGIBLE DEP�NDENT Any le�l dependent of an Enrollee of Group wtro meets the criteria for eli�b�tify established by Group and I
approved by VSP under s�fion VI.ELIGIBILITY FOR COVERAGE of fhe Group Pfan documsnt maintained by '
your Group Administrator under which such Enrollee is cover�.
EMERGENCY CONDITION A cartdition, wifh�dden onset and acute symptoms, that requires the Covered Persfln to obfain immediate
medicaf care,or an unfores�een oocurrence requiring irranediate,non-medical action.
ENROLLE� An ampfoyes or member of Group who meets the oriteria for e�gibiiity specified�der s�ecGon VL ELIGlBILITY
FOR COVERAGE of the Group Plan documeni mainfained by your Group Administrata�.
EXPERIMENTAL NATURE Proced�e or lens that is rat ussd universa(ly or acxepted by the vision care profession, as determined by
VSP.
GROUP An employer or ofher entity which contracts with VSP for coverage under this plan in order to provide vision
care coverage to its Enrollees and their Eligible Qependents,
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FCERATOCONUS A development or dystrophic�ormity of the comea in which it becomes ca�ashaped due to a ihinning and
sfcetching of the 6ssue in its central area.
MEMBER DOCTOR An optometrist or ophth�moloc,�'st lioensed and otherwise qu�ified to practice�rision care ar�dlor provide vis�on
ca�e matsrials who has von6acted wEth VSP to provide vision care senrices andla vision care materiais on
behalf of Covered P�ersons of VSP.
NON•MEMBER PROVIDER Any opforr�etrist, opbcian, ophfhalmobgst, or other I'icensed �d q�fified vision c�e provider who has not
contracted with VSP to provide vision care servic�ss andlor vision care materials to Covered i'srsons of VSP.
PLAN BENEFITS The vision care services and vision care materials which a Cov�ared Person is entitled to teceive by virfue of
coverage under this plan,as defined on the e�x�osed insert or in the Sct�du{e of 8ene6ts attached as Exhibit
A to tlie Group Plan doc�nent maintained by your Group Adrrinlstrator,
PREMIUMS The payments made to VSP by or on behalf of a Covered P�sa1 to entitle himlher to P(an Benefits,as stated
in the Schedule of Premfums attached as Exhibit B t� the t�aip Plan document maintained by your Group
Administrator.
RENEWAL DATE The date on which t�is pfan shall renew or terminate if proper no�ce is given.
SCHEDULE OF BENEFITS The document, attached as Exhibit A to the Group Plan document maintained by your Group Administrata,
which lists the vision care sennces and vision care materials which a Covered Person is�tined ta receive by
virlue of this plan.
SCH�DULE OF PREMIUMS The document, attached as Exhibit B to the Gro� Plan document maintained by your Group Administrator,
which states the payments to be mada to VSP t�or on behalt of a Covered Pason to entitle him(her to Plan
Benefits.
2 .
ELIGIBILiTY FOR COVERAGE
ees: To be eligil�e for coverage,a person must currenUy be an err�loyee or member af fhe Group,and meet the criteria established in the
ooverage criteria mutuslly agresd upon by Group and USP.
Eli�ble Deoendents: If dependent coverage is provided, the persons�igible tor coverage as dependents shalf include tha legal spouse of any
Errollee,and any unmarried child of an Enro�ee who has not attained the limibng age as shown ar�lhe enc[osed inserfi,including any natural child
fcom the rr�ment of birth,iegally acioptad child from ihe mom�►t of placement for adoption with the Enrollee,or oihe�child for whom a court holds
fhe Enrollee rasponsible.
A�t, unmamed chifd over Ihe limi6ng age as shown an the enclosed insert may conGnue [o be etigible as a dependent if the ohild is
incapable of self-sustaining employmen# because of inent� or physical disabiliry, and chiefly dependent upon the Enrollee for support a�d
main#enance.
ANNUAL EMROLLMENTIDISENROLLMENT
Except for nsw Enrollees joining t�is plan, Enraflees and Eligible Dspendents shall have the right to become covergci 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 othenNise be
allowed by mutual agreement betwieen the Group and VSP). Any such coverage or canceEfa6on of coverage may be acca�fished only by Group
giving VSP written natice thereof on behalf of the Enrollee or Eligible Dependent befiore the er�d of the prescribed thirty{34)day period and will take
effeat on the anrriversary date folbwing receipt of such notice.
PREMIUMS
Your(�oup is rssponsible for payments to VSP of the periodic charges for your coverage. You wilE be no6fied of your share of the charges, if any,
by your C�aip. The en6re cost of the pro�am is�aid to VSP by your Group,
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PROCEDURES FOt2 i1SING 7HIS PLAN
PLEASE READ TH�FOLLOWING INFORMATION SO YOU WIIL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE
MAY BE OBTAINED.
1. Vlfien you desire to obtain Plan B�enefits from a Member poctor,you should contact a Member doctor or VSP. A list of names,addresses,and .
ptror�e numbers oi Member poctors in your g�graphic bcation can be obtained from your Group,Plan Ac�ninistrator,or VSP. if ihis list does
no#crover ihe geographic area in which yau des'sre to seek services,ycw may call or write the VSP oflice nearest you to obtain one which does.
2, lf you are eli�ble for Plan Beneiits, VSP will provide Benefit AutF�oriza6on directly to the t�Aember�ctor, If you contact a Mernber poctar
directly,you must id�tify yourself as a VSP member so tt�e doctor knows to obtain Benefit Aufhoriza6on from VSP.
3. When such Benefit Authorizatian is provided by VSP and services are performed prior to the expiration date of the Benefit Authorization,tltl�is will
consGtute a claim against this pfan in spite of your,termination of coverage or ihe termination of this plan.Should you re�ive s�rvices from a
Me�er poctor without such Beneflt Authaization or obtain s�vices from a provider who is nat a Member doctor, you are responsible for
payrr�nt in full to the provider,
4. You pay only fhe Copayment(if any} to the Member poctor for the services coverad by tl�is plan. VSP wilf pay the Merr►ber poctor directly
according to their agee.ment wilh the doctor. VSP reimburses its Member poctors on a fee-for-service basis. There are no incen6ves or
financial bonuses paid to Member poctors for s�v+ces covered under this pfan.
Note: tf you are eligible for and obtain Plan Benefits from a Non-Member Provider,you should pay the provider his fui)fee. You will
be reimbursed by VSP in accordance with the Non-Member Provider reimbursement schedule shown on the enclosed insert,fess any
applicable Copayments.
5. In emergency conditions,when immediate vision care af a medical nature such as tor bodily trauma or disease is necessary, Covered Pers4n
can obtain covered ser�rices by contacGng a Merr�er poctor(w Out-of-Network Provider if Ihe attached Schedule of Benefits indicates Covered
F'erson's Plan ir�cludes such coverage). No prior approval from VSP is required for Covered Person to obtain vision care for Emergency
Condi6ons of a medical nattue. However, services for medical cancitions, induding emergencies, are covered by VSP only under the Acufe
EyeCare and Primary�yeCare Plans. If coverage fa�one of Ihese pfans is not incficated on the attached Schedule of Beneflts or Addendum,
Covered Person is not covered by VSP for medical ssrvices and sho�d contact a physician tmder Covered Person's medical insurance plan far
care. For er�rgency conditions of a�an-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's
Customer Setvice depa►�tment for assistance.
Emergency visia�cane is subject 6o the same beneGt frequencies,pl��lowances,Copayments and exclusions sfated ti�ein. Reimburssrr�nf
to PR�nb�D�tors will be made in acoadance witl�iheir agreement with VSP.
6. (n the event of terminadon of a Member poctor's me�r�ership in VSP,VSP will remain liable to the Member poctAr for services r�der�d to you
at the t�ne of termination and permif Merr�ber poctor t�coniinue to provide you wiih P(an 8�efits until the services are completed or until VSP
makes reasonable and appro�iate arrangements for the prrnri�on of such services by another authorized doctw.
BENEFIT AUTHORIXATION PftOCESS
VS1'authorizes Plan B�efiis according to the Iatest eligibi(ity informa6on fumished to VSP by Covered Person's Group and fhe le�of coverage
(i.e.service frequenaes,covered materials,reitr�ursement a+nounts,I�nitations,and exclusions)purchased fa Covered Person by Group under this
Plan. When Covered Person requests services under this Plan, Covered Person's prior u6�'ization of Plan Benefits will be reviawed by VSP to
determine if Covered Ps�rson is eligibie for new services based upon Covered Person's Plan's level of coverage. Please refer to the attached
Schedule of Bene�ts for a summary of�►e level of coverage provided to Covered Per�n by Group.
� A. Appeals: ]f VSP denies the doctata's request for prior authorization, the doctor, Covered Person or the Covered Person's autliorized
rBpresentative may request an appeal of the deniai. Please refer to the s�ecUon on Claim Appeals,below,for detaiis on how to request an
appeal. VSP shall provide the requestor with a final review determination within thirty(30)cafendar days irom the date tlie request is
received. A second level appeal, and other rerr�ies as described below, is alsfl available. VSP sha{I resotve any second levef appea!
within fhirty {30) calendar days. Covered Person may des�gnate any person, including the provider, as Coversd Person's authorized
representabve,
For more information regarding VSP's critaria for authorizing or denying Plan Benefits,please contact VSP's Customer Setvice De�artmen� �
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SENEFITS AND COVERAGES
Throu�its M�nber poctars, VSP provides Pian Benefits to Covered Persons, subjeat�fhe limitations, exclusions, and Copayment(s)desaibed
herein. When you wish to obhain Plan Benefits from a M�nber poctor,you should contact the Member poctor of yair chace,iden6fy yourself as a
VSP member, and �hedule an appointment, If you are eli�ble for Plan Beneflts, VSP wPll provide Benefit Authoriza6on for you direcfty to the
Member poctor prior to your appoinUnent
IMPORTANT: The benefits described betow are typical services and materials available under most VSP pians.However,the actuai Plan
Benefits provided to you by your Group may be differenE.Refer to the attached Schedule of Benefits and/or Disclosure to determine your
specific Plan Benefits.
1. Eye Examination: A complete ir�6af vision analysis which includes an appropriate examina6on af visual functions,including the prescrip6on o€
co►recUve ayawear where indicated. Each Covered Persfln ls entitled to a�ye Exarr�nation as indicated on t�e enclosed insert.
2. Lenses: The Member poctor wi11 order the proper lenses necessary for yaur visua)welfare, The doctor shafl verify the accuraoy of the finished
lenses. Each Cover�d Person is entitled to new lenses as indicated on the enclosed insert.
3. Frames: The Member Qoctor wiil assist in the selecGon of frames,properly frt and adjust the frames,and provide subsequent adjustments to
frames to maintain comfort and efficisncy. Each Covered Person is entl8ed to new frames as indicated on fhe enclosed insert.
4. Contact lenses: Unless ofhervvise indicated on f�e enclosed insert,contact lenses are available under ihis Plan in lieu of all other lens and
frame beneflts described herein.
When you obtain Necessary contact lenses from a lNember poctor, professional tees and materials will be covered as indicated on the
enclosad insert.
When Elective contaet lenses are obtained from a PAember poefor, VSP wifl provide an allowanca taward the cast of�ofessional fees and
materiaEs. A 15%discount shall also be applied to the Member poctors usual ar�customary professional fees for contact lens evaluafion and
f��ing. Contact lens materials are provided at the Member Dvctor's usual and customary charges.
5. If you elect to receiva vi�on care sQrwices from one of the Member poctors,Plan 8ehefits are provided subject only to yaur payment oi any
applicable CopaymertL If your Pl�includes Non-Member Provider coverage and you choose to obtain Plan Benefits from a Non-Member
Provider,you shoufd pay the Non-Member Pravider his fuli 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 SCNEDULE 1MLL BE SUFFICIENT TO PAY
FOR THE EXAMINATION OR THE MATERIALS. Availabiliiy of senrices under the Non-Member Provider re�mb�sement schedule is subject to
the same 6me limits and Copaytnents as those described for Member Qoctor seivices. Senrices obtainad from a Non-Member Provider are in
lieu of obtaining se�vices from a Member poctor and count toward plan benefit fr�equencies.
6. Low Usion SeNices and Materials{applicable only if incfuded in your Plan Bsnetits outlined on the encfosed insert): The Low Usion Benefit
provides special aid for people who have acuity or visuaE field loss that cannot be corrected wilh regular len�s. If a Covered P�son falls within
t�is category,he or she will be entiUed to professia�al senrices as well as ophthalmic materials including but nof limite�to suppl�nentaf tes6ng,
evaluations,visua!fraining,low vi�an prescription services,plus optical and r�n-opUcal aids,subject to the frequency and benefit limitations as
ou8ined on the endosed insert. Consult your Member poctor far details.
COPAYMENT
The benefits described herein are available to you st�ject only to your payment of any applicable Copayment(s)as described in this booklet and on
the enclosed insert.ANY ADDlTIQNAL CARE, SERVICE AND/OR MATERIALS NOT COVERED 8Y THIS PLAN MAY BE ARRANGED BETWEEN
YOU AND THE DOCTOR.
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EXCLUSIONS AND LIPAITATIONS QF BENEFITS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits,or may be subject to addikiona!limitatians. Covered
Persons may obtain details regarding frame brand availabiEity trom their VSP Member Ooctor or 6y calling VSP's Customer C�e Uivision
at(800)877-7195.
This Pian is designed to cover visual needs r�her than cosm�eac materials.if you select any of the fotlowing extras,this Plan will pay the
basic cost of the allowed lenses or frames,and you wiEi be responsibte for the addiEional costs for the options,uniess the extra is defined
as a Rtan Benefit in fhe enclosed Schedule of Benefits fnsert.
• Optionai cosme�c pracesses.
• An8-reflecUve coating.
• Color coating.
• Mirror coating.
• Scratcf�coating. �
• Blended lenses.
• Cosmetic lenses.
• l.aminated lenses.
• Oversize lenses.
• PolycarbonaEs lenses.
� Photochromic I�ses,tinted lenses excepf Pink#1 and Pink#2.
� Progressive mulGfocal lenses.
� UV(ultraviolet)protected lenses.
• Cert�n limitatia�s on low vision care.
NOT COVERED
There is no benefit under this plan for professional senrices or materials connected with:
• OrUtop6cs or vision training and any associated suppfemental testln�plano lenses{less than t.�0 c�opter powsr);or two pair of�asses in lieu
of bifocals.
• Replacement of lenses and frames furnished under this plan which are lost a�broken except at the normal intervais when services are
othe�wise availabte.
• Medicai or surg'�;al treatment of the eyes. �
• Carec6�e vision Ueatment of an Experimentai Nature.
• Costs for services and/or matarials above Plan Beneftt allawances in�icated on the enclosed insert
• Services/materials not indica#ed as covered Plan Benefits on the enclosed insert.
LlABILI7Y IN EVENT OF NON-PAYMENT
In the event VSP fails to pay the provider,ycw shall not be liable for any sums owed by VSP otlier tt�an those not covered by lfie poNcy.
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COMPLAINTS AldD GRIEVANCES
If Covered Persai ever has a quesUon or problem,Cavered Person's first step is to call VSP's Custotner Service Department.The Custaner Senrice
C?epartrr�nt will make every effort to answer Cavered Person's ques�on and/or resolve the matter informaily. If a matter is not iniiially resolved to the
sa6sfaction of a Covered Rarson,the Covered Person may communicate a corn�aint or grievance to VSP oraliy or in wri4ng by using the complaint
fotm that may be obtair�ed upon request irom the Customer Service Department Complaints and �ie►�ces include disagreements regarding
access to care, or the quality of care, treatment or service. Covered Persons also have fhe rigfrt to submit writfen comments or supporting
documentation�nceming a compfaint or grievar�ce to assist in VSP's review.VSP will resolve the cornplaint or grievance within thirty(30)days aitar
receipt.
Claim Pavments and Denials
A. Initial Determination: VSp will Ray ar deny claims wiihin thiRy(30)calendar days of ti�e receipt of the claim from the Covered Person or
Covered Person's aufhorized representative. ln the ev�t that a claim cannot be resolved within fhe 6me indicated VSP may, if necessary, extend
the time for decision by no more than fdtaen(15)calendar days, I
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B. Request for Appeals; If a Cover�Person's daim for bet►efits is denied by VSp in whole or in part,VSP will nobfy the Covered Persor�in
writing of the reason or reasons for ihe denial.Wit�in one h�dred eighty(180)days after receipt of s�h notice of deniaE of a claim,Covered Person
may make a verbal ar written request to VSP for a full review of such denial.The raquest s�ould contain sufficient informafion to iden6fy the Covered
Person for whom a claim tor beneflts was denied,including the name of the VSP EnrdEee, Member ldentificaGon Number af the VSP Enrollee, the
Covered Person's natne and date of birth, the name af the provider of services and the claim number.The Covered Person may state ths reasons
tlie Covered Person believes that the cfaim denial was in error. The Covered Persan may alsfl provide any pertinent documents to be reviewed.
VSP will review tha claim and�ve the Covered Person Ihe opportunity to review�rtinent documents, subrrot any staterrtents,documents,or written
arguments in support of the claim, and appear personally to present matsrials or arguments. Covered Persan or Covered Person's authorized
represen�aBve should submit all requests for appeals to:
VSP
Member Appeals
3333 Quality Orive
Rancho Cordova,CA 956T0
(800)877-7195
VSP's determinaaon, including speciftc reasons for the decision, shall be provide� and communicated to the Covered Person within thiriy (30)
calendar days after receipf of a rsquest fot appeal trom the Covered Person or Covered Person's aufharized repres�►ta6ve.
UVhen Covered Person has completed ail appeals mandated by the Emp{oyee Retirement Income Security Act of i974 ("ERISA"j, additional
voluntary altema6ve dis�ute resolutlon op6ons may be available, including media6on and arb'stration. Covered Person should contact the U. S.
Qepartment of Labor or the State insur�nce regulatory agency for detaNs. Additianal(y, under ERISA (Section 502(aj(1)(B)} [28 tl.S.C,
1132(aj{9)(B}], Covered Perscm has fhe right t�bring a avil(oourt)acGon when all availabte levels of denied daims, including the appeal process,
have been completed,tl�e claimswere not approved in wh�fe or in��,and Covered Person disagrees with the outcome.
C, Re�iew by the Department of Managed Ftealth Care:The California De�artment of Managed Health Care is responsi�e for regulating
health care service plans, If you have a�ievance against yaur health plan,you should first telephor�your health plan af(800)877-7195 and use
your health plan's grisvanc�process bafa�contacEing the Department Utilizing this grievance procedure does not prohibit any poten6al legal ri�ts
or remedies that may be available to ycw. If you need help with a grievance involving an emergency, a grievar�e that has not been sa@sfactorily
resolved by yoour health plan,or a grievance tl�at has remained unresolved for more tt�an 30 days,you may calf I�e Qepa�trrrent for assistance,
The De�rUnent�so has a tdl-free telephone number(1�88-NMO-22i9},a TDD line(1-877-688-9891)for the hearing impaEred and its Internet
Web site(http:!lwww.hmohelp.ca.gov)has�mplaint fo�rns online.The plan's grievance process and ihe Dapartment's complaint review process are
in addition to any other dispute resolution procedures that may be avaiEabfe to Covered Persons,and the fa'rlure to use tl�ese procedures does not
predude Covered Person's use of any ather rernedy provided by law.
ARBITRATION
Any dispute br questian arising beiween VSP and C�aip or any Covered Person involving tl�e application, interpretaGon, or performance under this
plan shall be seitled, if possibls, by amicable and informal negotiaGons. This wil! allow such �portunity as may be appropriate under the
circumstances for fact-finding and mediation. If any issue canrrot be resolved in ihis fashion, it shalf be submitted to arbitration. The procedure for
arbitration hereunder shal(be conducted pursuant to the Rules of the American Arbitra6on Associa4on,
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TERIUINATION OF BENEFtTS .
Tem�s and cancellation c�nditions of fhis plan are shouvn on the enclosed ins�t Plan Benefits will cease on the date o�cancellation of this plan
whether tha cancellatior�is by(�oup or by VSP due to non-payrrient of F'remium. If service is being rer�ed to you as of the terminati�on date of
this p{an,such service shaif be c�n6nued to complelion,but in no event beyond six(6)months after the temenation dats of this plan.
INDNIDUAL CONTINUATION OF BENEFITS
This program is available to c�oups of a rr�nimum of ten (10)employees and is, Iherefore, not avaifable ori an individual basis. Wheri a Group
terminates iis coverage,individual coverage is not a�Eable for Enrollees of tl�e Group who may desire to retain their coverage.
THE CQNSOLIDATED OMNI6US BUDGET RECONCI�IATION ACT OF 1885(COBRA� '
The Consolidated Omnibus Budget Recanciliation Act of 1985(COBRA}requires that,under certain cir��nstances,health p!an�neC�ts available to
an aligible Enrollee and his or her Eligble Dep�dents be made available for purchase by said pe�'sons upon the occurrence of a COBRA-qualifying
event. If,and ortfy to the extent COBRA applies,VSP sh�l make ihe statutorily-required con6nuaflon coverage available far p�chase in aocordance
with COBRA.
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UISIQN SERVICF PLAN
3333 Quallty Drive
Rancho Cordova, CA 95870
Group 1Vame: CITY OF PALM DESER�
Plan Number: 00408001
Effective Dafe: JULY 9, 2012 �
Plan Term: 7WENTY FOUR(24)MONTHS
VISlON CARE PLAN
DISCLOSURE FORM AND EVIDENCE OF COVERAGE
P1�4N ADM/NlSFRArOR: Lori Carney
{Name) �"
T3510 Fred Waring Dr
(AddressJ
Pa(m Deser� CA 92260-2524
(City, Sfate, Zrp)
MONTNLY PREMIUM: YOUR GROUP IS RESPONSlBLE FOR PAYMENT TO VlSION SERVICE
PLAN OF THF PERlODIC CNARGES FOR YOUR COVERAGE YOU WILL
BE NOT(FlED Of YOUR SHARE Of TNE CHARGES, !F ANY, BY YOUR
GROUP.
EL�GIBILfTY: ENROClEES & �L1G18LE DEPENDENTS: UNMARRIEp DFPENDENT
CHILDREN ARE COVERED TO AGE 19 OR TO AGE 23 JF FUZL-TlME'
Si"UQENTS. THE WaITtNG PERIOD fS �NE SAME AS YOUR OTNER
NEALTH BENEFITS.
PLAN ANb SCH�DULE: SlGNA�URF PLAN
FXAMINATlON: ONCE EVERY 12 MONTHS.
LENSFS: ONCE EVERY 12 MQNTNS
FRAMES: ONCE EVERY 24 M�NTHS.
TERM,TFRMINATION AND RENEWAL: AFTER THE PLAN TERM, TNIS PLAN Wil.L CONTINUE ON A MQNTN TO
MONTN BAStS OR UNTIL TERMINATED BYEITHER PARTYGiVING THE
OTHER SlXTY(60)DAYS PRIOR YVRlTTEN NOTICE.
Tl�PE OFAQMtNISTRATION: BFNEFITS ARE FURNfSHED UND�R R VlS10N CARE PLAN PURCHASED
8Y 7'NE GROUP�4ND Pf?OVIDED 8Y VISION SERVICE PLAN(1/SP)
UNDER WNlCH VSP IS FINANCIALLY RESPQNSf6LE FOR THE PAYM�NT
OF ClAlMS.
VSP'S ADDRESS 1S: VISION SERVICE P1AN
3333 QUAUTY DRIVE �
RANCHO CORDOVA,CA 95&70
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SCHEDULE OF BENEFITS
GENFRA
This Schedule and any Addi6onal Benefit Rider(sj, when pu�chased by Group,atfached hereio list the vision c�e services and vision care maferia(s
to whic�Covered Persons of VSA are en6tled,subject to any Copayments and ori�er oondi�ons,�mita6ons�d/or exdasions stated herein. !f Wan
Benefi6s are avariable for Non-MemGer Provider services as indicated by the reimbursement provisions below, visron care services and vision care
maferiafs may be received trom any ticensed op[omefris� ophfhalmdogis� or dispensing eptiaan, whe�er Member poctors or Non-Member
Providers.
� When Plan 8enefiGs are received from Member doctas,benefi�s appearing in U�e ftrst edumn below are applrc�le subject fo any Copayment(s)as
stated below. When P�an 8enefits are av�lable and received from Non-Member Providers,you are reimbtrrsed for such beneftis according b the
schedule in ihe secrond coktmn belawless any applicable Copayment
PLAN BENEFlTS MEMBER DOCTOR BFNEFIT NON-MEM9ER PROV�DER BENEFIT
VISION CARE SERVICES
Vision Examination Covered ln full` Up to$ 50.OQ"
VlSIO�t CARE MA R� IALS
Lenses
Single�sion Goveredln Full* Up to$ 50.QO*
Blfocal Covered in Full" Up to$ 75.00*
7rifocal Coverad in Fut1* Up to$ 100.40*
tenticular Covered in Ful(" Up to$ 925.00*
Frames Covered up fo Plan Allowance* Up to$ 70.00*
Frame attowance may be applied fotvards rron-prescription sunglasses for post PRI�l.ASII�or Custom tASIK pa6enis.
CONTACTL�NSES
Necessary .
Professionaf Fees and Materials Covered in�u1P Up to$ 210.00*
Elecfive Materials Professionat Fees
and Maferials
Up fo$?30,00 Up#o$ 105.00
Elective Contact Lens 5t6ng and avalua�ora" �
services are cavered in fufl once every 12 j
months,atFer a maximum$60.00 Copayment �
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Necessary Confacf Lenses are a P(an 8enetrt when spea6c benefit criteria are sa�sbed and when presaibed by Covered Pe►sor►'s Member poctar �
or fYat-Member Provider.Prior revisw artd approv�l by VSP are not required for Covered Persor+fo be eligibla for Neoessary Contad Lenses.
When contactlenses are obt�ned,the Covered Person shaA not be eligibla fo�r lenses and frames again for 12 months, i
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*Subjecf to Copayment,if any. �
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*"95%discount applies to Member poctor's usuaJ and cusfomary professiona!fees for contacf lens evalua�ion and fitting. �
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COPAYMENT
A Copayment amQunf of$i0.00 shaR be payable by!ha Covered Person to ihe Member pocfor or Non-Member poctor ef the time services are
rendered,
LOW V1SlON
Pro�essiona!servic�s for severe visua(problems not correc�ed with regular lenses,inciuding:
Supplemental Tes6ng Covered in Full Up to$125.00 �
(inctudes evaluaBon,diagnasrs and prescrip6on of vision aids where indicated)
Sup�lemenfa!Aids 75%of cost 75�of cost
Maximum allowable for aR Low Vision bene�ris of$9000A0 every fwo{2J ysars.
TN1S FVlQENCE OF CQVERAQE CQNSTITU7ES ONLY A SUMMARY OF TNE VISIQN PL�41V. TNE V/S10N PLAN UOCUMENT MUSF BE
CONSUL7ED TO DETERMfNE TNE EXAC7 TERMS AND COND1710NS OF COVERAGE.
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Exhibit C
ADDITIONAL BENEPIT RIDER
COVERED CONTACT LENSES
6ENERAL
This Rider lists addi�onal vision care benefits to which Covered Persans of VISION SEF2VICE PLAN are en6Bed, subject to any Copay��nts and
other conditions,kmitaGons andlor exdusions stated herein.This Rider forms a part of fhe Pdicy or Evidence of Coverage to which it is attached.
ELIGIBIUTY
The following are Covered Persons under this Plan:
• EnroAee.
• The legai spouse of Enrollee.
• 'fhe domestic partner of tlie same or opposite gender as�nrdlee,pursuant to Group's eligibility rulss.
• Any unmarried chiid of Enrdlee, inciuding any natural chdd from the date of bi�1h,legally adopted child from the date of placement for adoptiai
with the Enrollee,or other chifd ior whom a court ar adminisUaGve agency holds the Enroilee responsibie.
Unmarried dependent chi(dren are covered up to age 19,or to age 23 if full-Hme siudenfs.
See Scheduie befow for Plan Benefits,payments and/or reimbursement subjecf to any Gopaymeni(s)as stated:
COPAYMENT
A Copayment amount oi$50.00 sh�l be payable by the Covered Person at the Gme services are rendered.
The Copayment shall be required for professional senrices related to the fit6ng oi hard contact lenses,soft contact lenses, mulUfocal conhact lenses
or extended wear(firm or soft)contact lenses.
BECAUSE OF THE UNIQUE NATURE�F�ITTING CONTACT LENSES, EXPERIENCE HAS SHOWN THAT THERE MUST BE SUBSTANTIAL
PATIENT MOTIVATION.THERE IS ALSO SIGNIFICANT TIME INVOLVED ON THE QOCTOR'S PART V�METHER OR NOT THE PROCEDUF2E IS
SUCCESSFUL.FOR THESE REASONS,THE COPAYMENT IS NOT REFUNDABLE TO THE COVERED PERSON IN ANY CASE.
PLAN BENEFITS
Persons covered under fhis additional benefit are entitled to contacf lenses fhat are referrad to by VSP as"Covered,'as opposed to those that are
� de8ned as"Necessary'or"Electiva°
MATERIALS MEMBER UOCTOR BENEFIT FRE4UENCY
Confact lenses Covered in fuil,up to a one-year supply* Available once every 12 months**
Contact Lenses,once furnished under this plan,can on{y be teplaced with priar authorization from VSP.
'Less any applicable Copay�nt
"B in wi�the first date of service.
Cavered Persons may receive protessional services and the contact lensss associated fherewith fran a Member poclor, if, in �e opinion oi the
Member poctor,the patient can successful(y wsar contact lenses.This Plan covers the inidal fit6ng period of up to 90 days.This may be extended at
the discretion of fhe doct�. THIS BENEFIT DOES NOT AFFEC7, NOR IS IT AFFECTED BY, THE COVERED PERSQN'S ELIGIBIUTY FOR
SPECTACLE LENSES AND FRAMES UNDER ANY OTNER VSP PLAN.
EXCLUSIONS AND LIMITATtONS OF BENEFITS
NOT COVERED
There�e no beneflts tor professional services or maberials connectsd wilh:
12
• Qrthokerafiofogy(a procedure using contact(enses to change the shape of ft�e comea in ord�to raduce myapia}.
• Repiacement of lost or damaged lenses. �
• Modifications of(snses,
• Ar�sqcaily painted lenses.
• RouBne maint�ce such as polishing or clear�ng.
• Refifting(change in ler�s design)after the ir�tial�itting.
• Services andlor materials not indicated on tlus Rider as covered Plan Senefits.
SERVICES FROM NON-fl�EMBER PROVIDERS
LIABILITY OF COVERED PERSONS FOR PAYMENT
REfMBURSEMENI'PROVISIONS
When a Covered Person chooses fo receive services from a fdon-Member Provider, services may be secured irom any optome�ist,ophthalmologist
andlor dispensing optician. This plan then becanes an indemnity plari reimbur�ng according to a scheduie of allowances. The Covered Person
should pay the Providers fee in full.VSP wi0 reimburse the Covered Person in accordance with the following schedule.
THERE IS NO ASSURAN�E THAT THE AMOUiVT REIMBURSED WILL BE SUFFICIENT TO PAY THE MATERIALS IN FUI1.
AVAILABILITY OF SERVICES UNDER THIS REfMBURSEMENT SCHEDULE IS SUBJECT TO THE SAME TIME L(M1TS AND COPAYMENT AS
THQSE QESCRIBED FOR MEMBER DOCTORS.SERVICES 067AINED�f20M NON-MEMBER f'ROVIpERS ARE IN LIEU OF SERVIC�S FROM
A M�MBER OOCTOR.
VSP IS UNABLE TO REQUIRE NON-MEMBER PROVfDERS TO ADHERE TO VSP'S QUALITY STANDARDS.
SCHEDULE OF ALLOWANCES-NON-MENlBER PROVIDERS
PU1N BENEFITS
MATERIALS NON-MEMBER PROVIDER BENEFIT FREQUENCY
Extended•wear,disposable or dai[y Up to$25Q.00* Available once each 12 mon#hs�''
disposable contact lenses .
'Less any applicable Copayment
�*8e 'nnin with the fi�sf date of service.
13
•
�
VS � '
Vision Care for Life
CONTINUATION C(}VERAGE UN�ER CAL-COBRA
If you are covered under a�oup policy p�oviding coverage to 2 to 18�igible employees,you may be eligible to purchase conbnued coverage under
this group vision plan under Califomia Health and Safety Code SecUon 1366.20 et seq.(Gal-COBRAj.
You may qualify(o�Cal-C�BRA con6nuation coverage'rf you lose cove�age for one af fhe foilowing reasons:
a. Tfie death af tF►e covered employee.
b. The terminatiori of anployment or reduation in hours of the covered�nployee's employment,except lhat teimina6on fw�oss misconduct
does not cons8tute a qualitying avent �
c. The c�vorce or legaf sep�ati�n of the coverBd em�loyee trom the covered employee`s spouse.
d, The loss of dependent status by a dependent enroll�l in fhe group benefit plan.
a, With respect to a co�ered dependent only, the covered employee's enlitlement t�benefits under Title XVlli of the United States Social
Security Act(Medicare).
As a condition of receiving benefits,you must noGfy VSP wi�hin 60 days of the loss of c�vverage for one of the torsgoing reasons. FAILURE TO
NOTIFY VSP WfTHIN THE REQUIRED 60 DAY PERIOD WILL OISQUALIFY YOU FROM RECEIVING CONTINUATION COVERAGE.
You must request the continuation in wri�ng and deliver the written request[o VSP by 6rst class mail or other reliable means of delivery within the 60
day period following the later of(1}fhe date your covetage under fhe group ber�efit plan tatminated or will terminate by reason of a qualifying reason,
or(2)the date you were sent noUce from the groc�benefit plan or VSP of eGgbility to conti�e cowerage under Cal-COBRA.
In order to continue receiving coverage under this plan,you are responsible for making akl of the required premium payments in a�ord�ce with the
terms and c:ondiHons of ihe pian t�ntract. The first premium payment rtx�st be made to VSP by first-class mail,cerlifred mail or other r�iable r�ans
of de�ivery includ'mg personal defivery,express mail,or private courier within 45 days of the date you provided written no8ce to VSP of your election
of con�rwation of benefits. The first premium payment must equ�an�nount sufficient to pay any required premiums and afl premiums due. Failure
to submit the correcf pre�um arraunt within the 45 day p�iod wi{f disquali(y�u from receiving con6nuaGon coverage.
NoGce: If the contract befiiwaen VSP and the employer is terminated prior to the date yatr con6rwa6on coverage waild terrrinate pursuant to the
Caf-COBRA statute,you may elect continuaGon c�verage urxler the employer's subsequent group benefit plan,'rf any,lor the batance of the p�iod
you woedd have r�nained covered under this pl�. However, continuation coverage shail terminate if you fail t�c�mpty with 6�e requirements
pertaining to enrolUnent in and payment of premiums to tl�e new benefit�lan within 30 days of receiving notice af terrrrina6on of the prior�oup
benefit plan.
All nobces to VSP must be sent to:
VISION SERVICE PLAN
Attrt: COBRA Administration
3333 Quality Drive
Rancho Cordova, CA 95670
14
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