HomeMy WebLinkAboutES06-198 - Original - Vision Service Plan - Group Vision Care Plan - 01/01/2006 -tom R
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CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission to City Clerks Office. All
portions are to be completed, if you have questions, please contact City Clerks Office.
Vendor Name: yl t)1 0N �LI' Venclor Number:
JD Edwards Number
Contract Number:
This is assigned by Deputy City Clerk
Description: C200tO
Detail: vy\tamoR 's Nc)T 1:�LQIU,Rg-D BY
Project Name:
Contract Effective Date: - 01-0 (O Termination Date: I a-31-O t4
Contract Renewal Notice (Days): ICI f�
Number of days required notice for termira ion or renewal or amendment
Contract Manager: Department:
Abstract:
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VISION SERVICE PLAN
3333 QUALITY DRIVE
RANCHO CORDOVA, CALIFORNIA 95670
GROUP VISION CARE PLAN
ADMINISTRATIVE SERVICES PROGRAM
Group Name CITY OF KENT
Plan Number 12229020
State of Delivery WASHINGTON
Effective Date JANUARY 1, 2006
Plan Term TWENTY-FOUR (24) MONTHS
Administrative Fee Due Date FIRST DAY OF MONTH
In consideration of the statements and agreements contained in the Group Application
and in consideration of payment by Group of the admrmstrative fees and other amounts due 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 hereinafter set forth. This Plan is delivered in and governed by the
laws of the State of Delivery and is subject to the terms and conditions recited on the subsequent
pages hereof, which are a part of this Plan.
Gary Brooks, Senior Vice President. Operations
VSP-GVCP-ASP-6/99 12/08/05 Bbs
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TABLE OF CONTENTS
I. DEFINITIONS......................................................... ......................................................I
II. TERM, TERMINATION, AND RENEWAL...................................................................4
III. OBLIGATIONS OF VSP................................................................................................5
IV OBLIGATIONS OF THE GROUP..................................................................................8
V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN................................11
VI. ELIGIBILITY FOR COVERAGE.................................................................................15
VII. CONTINUATION OF COVERAGE.............................................................................19
VIII. ARBITRATION OF DISPUTES...................................................................................20
IX. NOTICES......................................................................................................................21
X. MISCELLANEOUS......................................................................................................22
EXHIBITA...................................................................................................................24
SCHEDULE OF BENEFITS..............................................................................24
EXHIBITB................................................................................................................. .29
SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE......29
I.
DEFINITIONS
Key terms used in this Plan are defined and shall have the meaning set forth as follows,
unless the context of a term's usage clearly requires otherwise.
1.01 ADMINISTRATIVE FEE The payments made to VSP by or on behalf of
Group in consideration of administrative services rendered.
1.02. ADMINISTRATIVE SERVICES PROGRAM: A group vision care plan
whereby Group pays VSP for the Plan Benefits in addition to a monthly Administrative Fee.
1.03. ADVANCE PAYMENT- The amount paid in advance to VSP by or on behalf of
Group to cover the estimated benefit costs of Group for one (1) month.
1.04. BENEFIT AUTHORIZATION Authorization issued by VSP identifying the
individual named as a Covered Person of VSP, and identifying those Plan Benefits to which
Covered Person is entitled.
1.05 CLAIMS AMOUNT: Total charges for benefits delivered, including the cost of
professional services and ophthalmic materials, charges for VSP services related to materials
purchased, and taxes.
1.06. CONFIDENTIAL MATTER: All confidential or personal information
concerning the medical, personal, financial or business affairs of Covered Persons acquired in
the course of providing Plan Benefits hereunder.
1.07. COPAYMENTS: Any amounts required to he paid by or on behalf of a Covered
Person for Plan Benefits which are not fully covered.
1.08. COVERED PERSON: An Enrollee or Eligible Dependent who meets VSP's
eligibility criteria and who is covered under this Plan.
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1.09. ELIGIBLE DEPENDENT: Any legal dependent of an Enrollee of Group who
meets the criteria for eligibility established by Group and approved by VSP in Article VI of this
Plan under which such Enrollee is covered.
1.10 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.
1.11. ENROLLEE: An employee or member of Group who meets the criteria for
eligibility specified under VI. ELIGIBILITY FOR COVERAGE.
1.12 EXPERIMENTAL NATURE- Procedure or lens that is not used universally or
accepted by the vision care profession, as determined by VSP.
1.13 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.
1.14. GROUP APPLICATION The form signed by an authorized representative of
the Groupto signify the Grou 's intention to have its Enrollees and their Eligible Dependents
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become Covered Persons of VSP.
1.15. GROUP VISION CARE PLAN (also, "THE PLAN"): The Plan provided by
VSP in favor of a Group, under which its Enrollees, 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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1.16. 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 and/or vision care materials on behalf of
Covered Persons of VSP
1.17. 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.
1.18. PLAN BENEFITS: 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 in the
Schedule of Benefits attached hereto as Exhibit A
1.19. RENEWAL DATE: The date on which the Plan shall renew, or terminate if
proper notice is given.
1.20. SCHEDULE OF BENEFITS: The document, attached hereto as Exhibit A,
which lists the vision care services and vision care materials which a Covered Person is entitled
to receive by virtue of this Plan.
1.21. SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE:
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 him to Plan Benefits.
1.22. VISUALLY NECESSARY OR APPROPRIATE: Services and materials
medically or visually necessary to restore or maintain a patient's visual acuity and health and for
which there is no less expensive professionally acceptable alternative, as determined by VSP.
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H.
TERM, TERMINATION, AND RENEWAL
2.01. Plan Term: This Plan shall become effective on the Effective Date and shall
remain in effect for the Plan Term. At the end of the Plan Term, it will renew on a month to
month basis unless either party notifies the other in writing, at least sixty (60) days before the
end of the Plan Term, that the party is unwilling to renew the Plan. If such notice is given, the
Plan will terminate at 12:00 midnight on the last day of the Plan Term, unless the parties reach
mutual agreement on its renewal. If the Plan continues on a month to month basis after the Plan
Term, either Party may thereafter ternunate the Plan upon thirty (30) days advance written notice
to the other party.
If VSP issues written renewal materials to Group at least sixty (60) days before the end 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 12.00 midnight on the last day of the Plan Term as
noted above.
2.02. Termination: In the event of termination of this Plan by either party, Group
agrees to provide funds for payment of the Claims Amount associated with Plan Benefits
provided pursuant to Benefit Authorizations issued prior to the Plan termination date, provided
claims for such Plan Benefits are filed with VSP within six (6) months after termination of this
Plan.
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III.
OBLIGATIONS OF VSP
3.01. Coverage of Covered Persons: VSP will enroll each eligible Enrollee and his
Eligible Dependents, if dependent coverage is provided, all of whom shall be referred to as
"Covered Persons." To institute coverage, Group may be required to complete and sign a Group
Application and forward such application to VSP, along with information regarding Enrollees
and Eligible Dependents, and applicable amounts due. (Refer to VI. ELIGIBILITY FOR
COVERAGE for further details.)
Following enrollment, VSP will provide Group with Vision Care Brochures for Covered
Persons. Such Brochures will summarize the terms and conditions of this Plan.
3.02. Provision of Plan Benefits: Through its Member Doctors (or through other
licensed vision care providers in cases 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 Benefits 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.
Benefit Authorization must be obtained prior to a Covered Person obtaining Plan Benefits
from a Member Doctor. When a Covered Person desires to receive Plan Benefits from a
Member Doctor. the Covered Person must schedule an appointment and identify himself as a
VSP Covered Person in order for the Member Doctor to obtain Benefit Authorization from VSP.
VSP shall provide Benefit Authorization to the Member Doctor to authorize the provision of
Plan Benefits to the Covered Person. Each Benefit Authorization will contain an expiration date,
allowing a specific period of time for the Covered Person to obtain Plan Benefits. Benefit
Authorization shall be issued by VSP in accordance with the latest eligibility information
furnished by Group and the Covered Person's past service utilization, if any. Any Benefit
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Authorization so issued by VSP shall constitute a certification to the Member Doctor that
payment will be made. VSP shall not be held liable to Group for any Benefit Authorization
issued in error in reliance on the latest eligibility information available to VSP as provided by the
Group.
VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any
applicable Copayment, within a reasonable time but not more than thirty (30) calendar days after
VSP has received a completed claim, unless special circumstances require additional time In
such cases, VSP may obtain an extension of fifteen (15) 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 covered only when they
are deemed Visually Necessary or Appropriate for the proper treatment of a Covered Person's
condition. Questions involving necessity or appropriateness of treatment shall be decided by the
doctor responsible for the Covered Person's care and are subject to review and final
determination by VSP. Any objections of a Covered Person regarding such decisions may be
made to VSP in accordance with VSP's grievance procedures (See Paragraphs 5 05 and 5.06).
3.04. Provision of Information to Covered Persons: Upon request, VSP will make
available to Covered Persons necessary information describing Plan Benefits and procedures. A
copy of this Plan will be placed with Group. The Plan will also be available at the offices of
VSP for copying or inspection by Covered Persons. VSP shall provide Group with an updated
list twice annually of Member Doctors' names, addresses, and telephone numbers for distribution
to Covered Persons. Covered Persons may also obtain a copy of the latest Member Doctor list
by contacting VSP's Customer Service Department in writing or via the toll-free Customer
Service telephone line, or by visiting VSP's Web site at www.vsp.com.
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3.05. Preservation of Confidentiality: VSP will hold in strict confidence all
Confidential Matters. VSP will also exercise its best efforts to prevent any of its employees,
Member Doctors, or agents, from disclosing any Confidential Matter. An exception would be if
disclosure is necessary to enable any of the above to perform their obligations under this Plan,
including but not limited to sharing information with medical information bureaus, or as may
otherwise be required by 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
Service Department or by visiting VSP's Web site at www vsp.com
3.06. Emergency Vision Care: When vision care is necessary for Emergency
Conditions, Covered Persons may obtain Plan Benefits by contacting a Member Doctor or Out-
of-Network 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 Acute 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 plans 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. Reimbursement and eligibility are subject to the terms of this
Plan.
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IV.
OBLIGATIONS OF THE GROUP
4.01. Identification of Eligible Enrollees: An Enrollee is eligible for coverage under
this Plan, if he satisfies the enrollment criteria specified in Paragraph 6.01(a) and/or as mutually
agreed to by VSP and Group. Group shall provide monthly eligibility information to VSP in a
mutually agreed upon format and medium to identify all Enrollees who are eligible for coverage
under this Plan. Group will supply to VSP, on or before the last day of each month, eligibility
information sufficient to identify all Enrollees to be added to or deleted from VSP's coverage
rosters for the coming month. The eligibility information shall include designation of family
status for each such Enrollee, if dependent coverage is provided. Group shall, when requested,
make available for inspection by VSP records having a bearing on the coverage of Covered
Persons under this Plan.
4.02. Claims Amounts and Advance of Payment: Group shall provide all funds
necessary to pay the Claims Amount associated with Covered Persons pursuant to this Plan. In
order to assure timely and adequate payment, Group agrees to make an Advance Payment as
outlined on the attached Schedule of Advance Payment and Administrative Fee, Exhibit B. This
Advance Payment is an estimate of the Claims Amount for one (1) month. Group agrees to pay
the actual Claims Amounts on a monthly basis within ten (10) days after receipt of VSP's
statement. The Advance Payment amount may be adjusted each Plan Term if the average of
monthly Claims Amount increases or decreases. The parties agree that such Advance Payment is
reimbursable to the Group upon termination of this Plan, after the Group's indebtedness to VSP
and/or its benefit providers has been satisfied. However, amounts paid to VSP as Advance
Payment shall not be considered assets of the Group, and need not be held m trust by VSP.
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4.03. Administrative Fee: Additionally, on or before the first day of each month,
Group shall remit to VSP an Administrative Fee as outlined on the attached Schedule of
Advance Payment and Administrative Fee, Exhibit B. Change will not be made to the
Administrative Fee during any Plan Term unless there is a change in the Schedule of Benefits or
a material change in any other terms and conditions of the Plan, provided any such change is
mutually agreed upon in writing between VSP and Group.
Notwithstanding the above, VSP reserves the right to increase amounts due hereunder
during a Plan Term by the amount of any tax or assessment not now in effect which is
subsequently levied by any taxing authority, which is attributable to the amount due VSP from
Group.
4.04. Grace Period: Group shall be allowed a grace period of thirty-one (31) days
following the due date for making any payment of amounts due under this Plan. During the
grace period, this Plan will remain in full force and effect for all Covered Persons. Late
payments will be considered by VSP at the time of Plan renewal and may impact Group's
Advance Payment and Administrative Fees in future Plan Terms.
If Group fails to make any payment of amounts due by the end of any grace period, VSP
may notify Group that the payment of amounts due has not been made, that coverage is canceled
and that the Group is responsible for payment for the Claims Amount associated with Plan
Benefits provided to Covered Persons after the last period for which amounts due were fully
paid, including the grace period and through the effective date of the termination. Group shall
also remain responsible for payment, in accordance with Paragraph 2 02, of any Claims Amount
associated with Benefit Authorizations outstanding at the time of termination, and for any legal
and/or collection fees incurred by VSP in collecting amounts due under this Plan.
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4.05. Distribution of Required Documents: Group agrees to distribute to Enrollees
any disclosure forms, plan summaries or other materials that may be 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 receipt or as otherwise required under state law.
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V.
OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN
5 01. General: By this Plan, Group makes coverage available to its Enrollees and their
Eligible Dependents, if dependent coverage is provided. This Plan may be amended or
terminated by agreement between VSP and Group as otherwise indicated herein. Consent or
concurrence of Covered Persons for any such amendment or termination is not necessary. This
Plan, and all Exhibits, attachments and amendments, constitute VSP's sole and entire undertaking
to Covered Persons under this Plan.
All Covered Persons under this Plan shall have the following obligations as a condition of
their coverage.
5.02 Copavments for Services Received: Where, as indicated on the Schedule of
Benefits, Exhibit A hereto, Copayments are required for certain Plan Benefits, these Copayments
shall be the personal responsibility of the Covered Person receiving the care and must be paid to
the Member Doctor (or Non-Member Doctor if Non-Member Provider benefits are indicated on
the attached Schedule of Benefits at Exhibit A) on the date the services are rendered.
5.03. Obtaining Services from Member Doctors: Benefit Authorization must be
obtained prior to receiving Plan Benefits from a Member Doctor When a Covered Person
desires to receive Plan Benefits from a Member Doctor, the Covered Person must select a
Member Doctor, schedule an appointment, and identify himself as a Covered Person in order for
the Member Doctor to obtain Benefit Authorization from VSP. Should the Covered Person
receive Plan Benefits from a Member Doctor without such Benefit Authorization, then for the
purposes of those Plan Benefits provided to the Covered Person, the provider will be considered
a Non-Member Provider and the benefits available will be limited to those for a Non-Member
Provider, if any.
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5.04. Submission of Non-Member Provider Claims: All claims for services received
from Non-Member Providers (if Non-Member Provider coverage is indicated on the attached
Schedule of Benefits at Exhibit A) shall be submitted by Covered Persons to VSP within one
hundred eighty (180) days of the date of service. VSP reserves the right to reject such claims
which are filed more than one hundred eighty (180) days after the date of service. Failure to
submit a claim within one hundred eighty (l 80) days, however, shall not invalidate or reduce the
claim if it was not reasonably possible to submit the claim within such time period, provided the
claim was submitted as soon as was reasonably possible and in no event, except in absence of
legal capacity, later than one year from the required date
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 to care, quality of care, treatment or service. Complaints and
grievances may be submitted to VSP verbally or in writing. A Covered Person may submit
written comments or supporting documentation concerning his/her complaint or grievance to
assist in VSP's review. VSP will resolve the complaint or grievance within thirty (30) days after
receipt, unless special circumstances require an extension of time. In that case, resolution shall
be achieved as soon as possible, but not later than one hundred twenty (120) days after VSP's
receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved
within thirty (30) days, VSP will notify the Covered Person of the expected resolution date.
Upon final resolution, VSP will notify the Covered Person of the outcome in writing
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
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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 request must be made within one hundred eighty
(ISO) days following denial of a claim and should contain sufficient information to identify the
Covered Person for whom the claim was denied, including the VSP Enrollee's name, the VSP
Enrollee's Member Identification Number, the Covered Person's name and date of birth, the
provider of services and the claim number. The Covered Person may review, during normal
working hours, any documents held by VSP pertinent to the denial. The Covered Person may
also submit written comments or supporting documentation concerning the claim to assist in
VSP's review. VSP's response to the initial appeal, including specific reasons for the decision,
shall be provided and communicated to the Covered Person as follows:
1. Prior Authorization for Visually Necessary or Appropriate
Services: within thirty (30) calendar days after receipt of a request for an appeal from the
Covered Person.
2. Denied Claims for Services Rendered- within thirty (30) calendar
days after receipt of a request for an appeal from the Covered Person.
b) Second Level Appeal: If the Covered Person disagrees with the response
to the initial appeal of the claim, the Covered Person has a right 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
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state and federal laws and regulations and shall include the specific reasons for the
determination.
c) Other Remedies: When Covered Person has completed the appeals
process stated herein, additional voluntary alternative dispute resolution options may be
available, including mediation, or Group should advise Covered Person to contact the U.S.
Department of Labor or the state insurance regulatory agency for details. Additionally, under the
provisions of ERISA Section 502(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
5.07 Time of Action: No action in law or in equity shall be brought to recover on the
Plan prior to the Covered Person exhausting his grievance rights as described in Paragraphs 5.05
and 5.06 above 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 expiration of six
(6) years from the last date that the claim and any applicable invoices may be submitted to VSP,
in accordance with the terms of this Plan.
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VI.
ELIGIBILITY FOR COVERAGE
6.01. Eligibility Criteria: Individuals will 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 established in the coverage criteria mutually agreed
upon by Group and VSP.
(b) Eligible Dependents: If dependent coverage is provided, the persons
eligible for coverage as dependents shall include:
(1) the legal spouse of any Enrollee, and
(2) any unmarried child of an Enrollee, including any natural child from
the moment of birth, or legally adopted child from the moment of placement for adoption with
the Enrollee, or other child for whom a court holds the Enrollee responsible; and
(A) for whose support the Enrollee is legally responsible. Such dependent
children shall be eligible until the end of the month in which they attain the age of 23 years,or
(3) as further defined by Group.
If 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. Coverage
will continue as long as he remains chiefly dependent on the Enrollee for support and the
Enrollee's coverage remains in force; PROVIDED satisfactory proof of the dependent's
incapacity can be furnished to VSP within thirty-one (31) days of the date the Eligible
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Dependent's coverage would have otherwise terminated, and at such other times as VSP may
request proof, but not more frequently than annually.
6.02. Documentation of Eligibility: Persons satisfying the requirements for coverage
under either of the above classes shall be eligible if:
(a) in the case of an Enrollee, the individual's name and Social Security Number
have been reported by the Group to VSP in the manner provided hereunder, and
(b) in the case of changes to an Eligible Dependent's status, the change has been
reported by the Group to VSP in the manner provided herein. As indicated in Paragraph 4.01
above, VSP may elect to inspect the Group's records in order to verify eligibility of Enrollees and
dependents. Plan Benefits will be available only to persons on whose behalf applicable amounts
due have been paid for the current period, or Grace Periods outlined above in Paragraph 4 04. If
a clerical error is made, it will not affect the coverage to which the Covered Person is entitled
under the Plan.
6.03 Retroactive Eligibility Changes: Retroactive eligibility changes are limited to
sixty (60) days prior to the date notice of any such requested change is received by VSP. If
coverage is retroactively terminated for an individual, Group shall remain responsible for the
Claims Amount associated with any Plan Benefits provided to that individual pursuant to the
Benefit Authorization issued by VSP in reliance on the latest eligibility information available to
VSP at the time of such Benefit Authorization.
6.04. Change of Participation Requirements, Contribution of Fees, and Eligibility
Rules: Composition of the Group, percentage of Enrollees covered under the Plan, and Group's
contribution and Group's 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
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composition, percentage of Enrollees covered, contribution or eligibility requirements. Any such
change which materially affects VSP's obligations hereunder must be mutually agreed upon in
writing between VSP and Group and may constitute a material change to the terms and
conditions of this Plan for purposes of Paragraph 4.03. Nothing in this section shall limit
Group's ability to add Enrollees and/or Eligible Dependents in accordance with the terms of this
Plan.
6.05 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 children, etc.) Group shall provide notice of such change to VSP via the
next eligibility listing required under Paragraph 4.01. If such notice is given, the change in the
Covered Person's status will be effective on the first day of the month following the request for
change, or at a requested later date. Notwithstanding any other provision in this section, a
newborn child will be covered for thirty-one (31) days after birth and an adopted child will be
covered for thirty-one (31) days after the date the Enrollee or Enrollee's spouse acquires the right
to control the health care of the child. To continue coverage for a newbom or adopted child
beyond the initial thirty-one (31) day period, the Group must be properly notified of the
Enrollee's change in family status and applicable amounts due must be paid to VSP on behalf of
the child
6.06. Family and Medical Leave Act: The federal Family and Medical Leave Act of
1993 (FMLA), requires that under certain circumstances health plan benefits available to an
eligible Enrollee and his or her Eligible Dependents be made available during certain periods of
leave. Benefits will be available at the level and under the conditions coverage would have been
provided if the eligible Enrollee had not gone on leave. If, and only to the extent, FMLA applies
17-
to the parties to this Plan, VSP shall make the statutorily-required continuation coverage
available based on the eligibility information provided by the Group.
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VII.
CONTINUATION OF COVERAGE
7.01. COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) requires that, under certain circumstances, health plan benefits available to an
Enrollee and his or her Eligible Dependents be made available for purchase by said persons upon
the occurrence of a COBRA-qualifying 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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VM.
ARBITRATION OF DISPUTES
8.01. Dispute Resolution: 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 m this fashion, it shall be submitted to arbitration.
8.02. Procedure: The procedure for arbitration hereunder shall be conducted pursuant
to the Rules of the American Arbitration Association in effect at the time of the dispute.
8.03. Choice of Law: Question(s) and dispute(s) hereunder are to be resolved by
arbitration. However, if there are any matters arising in connection with this Plan which do
become the subject of legal process, the applicable law shall be that of the State of delivery of
this Plan.
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IX.
NOTICES
9.01. Required Notices: Any notices to be given under this Plan to either the Group or
VSP shall be in writing and delivered by United States First Class Mail. Notices sent to the
Group will be mailed to the address shown on the Group Application. Notices sent to VSP shall
be sent to the address shown on this Plan Any notices may be hand-delivered by either party to
an appropriate representative of the party, with the burden being on the party effecting such
hand-delivery, to prove, if questioned, that such delivery was made.
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X.
MISCELLANEOUS
10.01. Entire Plan: This Plan, the Group Application, and all Exhibits and attachments,
and any amendments hereto, constitute the entire understanding between the parties and
supersedes 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 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. Indemnity: VSP agrees to indemnify, defend and hold harmless Group, its
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 arising from the failure of VSP, its officers, 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,
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 arising or resulting from the failure of Group, its officers or employees to perform
any of the duties or responsibilities specified herein.
10 03 Liability: VSP arranges for the provision of vision care services and materials
through agreements with Member Doctors, who are independent contractors responsible for
exercising independent judgement. VSP does not itself directly furnish vision care services or
supply materials. Under no circumstances shall VSP or Group be liable for the negligence,
- 22-
wrongful acts or omissions of any doctor, laboratory, or any other person or organization
performing services or supplying materials in connection with this Plan
10.04. Assignment: Neither this Plan nor any of the rights or obligations of either of the
parties may be assigned or transferred, except as noted herein, without the prior written consent
of both parties.
10.05. Severability: Should any provision of this Plan be declared invalid, the
remaining provisions shall remain in full force and effect.
10.06. Governing Law: This Plan shall be governed by and construed in accordance
with applicable federal and state law. Any provision that is in conflict 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. Communication Materials- All 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 in advance of mailing to Enrollees. 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 meet any applicable legal or regulatory requirements, including, but not
limited to, ERISA requirements.
- 23-
EXHIBIT A
VISION SERVICE PLAN
SCHEDULE OF BENEFITS
Enhanced Plan B
GENERAL
This Schedule lists the vision care services and vision care materials to which Covered Persons
of VISION SERVICE PLAN ("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,
ophthalmologist, or dispensing optician, whether Member Doctors or Non-Member Providers.
This Schedule forms a part of the Plan or Certificate to which it is attached.
When Plan Benefits are received from Member Doctors, benefits appearing in the first column
below are applicable subject 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 each Covered Person subject only to payment of
the applicable Copayment by the Covered Person. Copayments are required for Plan Benefits
received from Member Doctors and Non-Member Providers. Covered Persons must also follow
the proper procedures for obtaining Benefit Authorization
r frames) r r vi There shall be no Copayment for the examination. If materials (lenses and are provided,
ded,
there shall be a Copayment of $25.00 payable at the time the materials are ordered. However,
the Copayment for materials shall not apply to elective contact lenses.
PLAN BENEFITS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
VISION CARE SERVICES
Eve Examination Covered 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 once every plan year beginning on January 1st.
*Less any PP Copayment.
applicable Co a ment.
- 24-
VISION CARE MATERIALS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Lenses
Single Vision Covered in full* Up to $ 42 00*
Bifocal Covered in full* Up to $ 72 00*
Trifocal Covered in full* Up to $ 82 00*
Lenticular Covered in full* Up to $ 122.001
Available once every plan year beginning on January 1st.
Frames
Covered up to Plan Up to $ 45 00-
Allowance* gwr
Available once every other plan year beginning on January 1st.
*Less any applicable Copayment.
Lenses and frames include such professional services as are necessary, which shall include•
• Prescribing and ordering proper lenses;
• Assisting in the selection of frames;
• Verifying the accuracy of the finished lenses;
• Proper fitting and adjustment of frames;
• Subsequent adjustments to frames to maintain comfort and efficiency;
• Progress or follow-up work as necessary
-25-
S
Contact Lenses
Contact lenses are available once every 12 months in lieu of all other lens and frame benefits
available herein When contact lenses are obtained, the Covered Person shall not be eligible for
lenses and frames again for one plan year.
Visually Necessary — When Visually Necessary contact lenses are obtained from a Member
Doctor, they will be covered in full with prior authorization from VSP. When Visually
Necessary contact lenses are obtained 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 Member Doctor or Non-Member 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
Covered in full* Up to $210 00*
Elective - Contact lenses for other than Visually Necessary circumstances
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional * and Materials Professional a nd Materials
Up to $200 0- Up to $125.
*Subject to Copayment N o
**Additional discount applies to Member Doctor's usual and customary professional fees for
contact lens evaluation and fitting (see section on Additional Discounts below).
- 26-
ADDITIONAL DISCOUNT
Each Covered Person shall be entitled to receive a discount of twenty percent (20%) toward the
purchase of additional complete pairs of prescription glasses (lenses, lens options, and frames)
from a Member Doctor Additional pair means any complete pair of prescription glasses
purchased beyond the benefit frequency allowed under this Plan.
Additionally, Covered Persons shall be entitled to receive a discount of fifteen percent (15%) off
Member Doctor professional fees for elective contact lens evaluations and fittings Discounts are
applied to the Member Doctor's usual and customary fees for such services and are available
within twelve (12) months of the covered eye examination from the Member Doctor who
provided the covered eye exarmnation. Contact lens materials are provided at the doctor's usual
and customary charges. Additional discounts noted on this schedule are subject to change as
deemed appropriate by VSP with prior notification to the Group
LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual problems that
are not correctable with regular lenses and is subject to prior approval by VSP Consultants.
MEMBER DOCTOR NON-MEMBER
BENEFIT BENEFIT
Supplementary Testing Covered in Full Up to $125 00
Complete low vision analysis/diagnosis which includes a comprehensive examination of
visual functions, including the prescription of corrective eyewear or vision aids where indicated
Supplemental Care Aids 75% of Cost 75% of Cost
Subsequent low vision aids as Visually Necessary or Appropriate.
Copayment for Supplemental Aids: 25% payable by Covered Person
Benefit Maximum
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
NON-MEMBER PROVIDER BENEFIT
Low Vision benefits secured from a Non-Member Provider are subject to the same time limits
and Copayment arrangements as described above for a Member Doctor 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 Doctor in similar
circumstances. NOTE There is no assurance that this amount will be within the 25%
Copayment feature.
27-
EXCLUSIONS AND LIMITATIONS OF BENEFITS
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered
Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses,
and the Covered Person will pay the additional costs for the options.
• Optional cosmetic processes.
• Anti-reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
• Oversize lenses.
• Progressive multifocal lenses.
• Photochromic lenses; tinted lenses except Pink#1 and Pink#2.
• UV (ultraviolet) protected lenses
• Certain limitations on low vision care.
• A frame that costs more than the Plan allowance.
• Contact lenses (except as noted elsewhere herein).
NOT COVERED
There is no benefit for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing, plano lenses (less than
a±.38 diopter power); or two 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;
• 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-
EXHIBIT B
VISION SERVICE PLAN
SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE
Enhanced Plan B
VSP shall be entitled to receive amounts due for each month on behalf of each Enrollee and
his/her Eligible Dependents, if any in the amounts specified below:
ADVANCE PAYMENT: $9,860.68
ADMINISTRATIVE FEE:
$2.05 per month for each eligible Enrollee with eligible dependents
NOTICE: The amount due under this Plan is subject to change upon renewal (after the end of
the Plan Term or any subsequent Plan Term) or upon change of the Schedule of Benefits or a
material change in any other terms or conditions of the Plan.
-29-
VISION SERVICE PLAN
PLEASE ATTACH TO YOUR
GROUP VISION CARE PLAN
AMENDMENT TO GROUP VISION CARE PLAN
To be attached to and made part of Group Vision Care Plan Number 12229020 issued to CITY
OF KENT.
EXCEPT as specifically amended herein, said Plan shall remain in full force and effect.
IT IS HEREBY AGREED that effective January 1, 2006, the Group Vision Care Plan shall be
amended as follows-
X. MISCELLANEOUS
IT IS FURTHER AGREED that Exhibits A of the Group Vision Care Plan shall be amended as
attached hereto.
26
i ii i i
r 4
EXHIBIT A
VISION SERVICE PLAN
SCHEDULE OF BENEFITS
Enhanced Plan B
GENERAL
This Schedule lists the vision care services and vision care materials to which Covered Persons
of VISION SERVICE PLAN ("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,
ophthalmologist, or dispensing optician, whether Member Doctors or Non-Member Providers.
This Schedule forms a part of the Plan or Certificate to which it is attached.
When Plan Benefits are received from Member Doctors, benefits appearing in the first column
below are applicable subject 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 each Covered Person subject only to payment of
the applicable Copayment by the Covered Person. Copayments are required for Plan Benefits
received from Member Doctors and Non-Member Providers. Covered Persons must also follow
the proper procedures for obtaining Benefit Authorization.
There shall be no Copayment for the examination If materials (lenses and frames) are provided,
there shall be a Copayment of $25.00 payable at the time the materials are ordered. However,
the Copayment for materials shall not apply to elective contact lenses.
PLAN BENEFITS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
VISION CARE SERVICES
Eve Examination Covered 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 once every plan year beginning on January 1st.
*Less any applicable Copayment.
-24-
�4
VISION CARE MATERIALS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Lenses
Single Vision Covered in full* Up to $ 42 00*
Bifocal Covered in full* Up to $ 72.00*
Trifocal Covered in full* Up to $ 82.00*
Lenticular Covered in full* Up to $ 122 00*
Available once every plan year beginning on January 1 st.
Frames
Covered up to Plan Up to $ 45 00*
Allowance*
Available once every other plan year beginning on January 1 st.
*Less any applicable Copayment.
Lenses and frames include such professional services as are necessary, which shall include:
• Prescribing and ordering proper lenses;
• Assisting in the selection of frames;
• Verifying the accuracy of the finished lenses;
• Proper fitting and adjustment of frames;
• Subsequent adjustments to frames to maintain comfort and efficiency-,
• Progress or follow-up work as necessary.
-25 -
k
I <
Contact Lenses
Contact lenses are available once every 12 months in lieu of all other lens and frame benefits
available herein When contact lenses are obtained, the Covered Person shall not be eligible for
lenses and frames again for one plan year.
Visually Necessary — When Visually Necessary contact lenses are obtained from a Member
Doctor, they will be covered in full with prior authorization from VSP. When Visually
Necessary contact lenses are obtained 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 Member Doctor or Non-Member Provider are
subject to review and authorization from VSP's Optometnc Consultants.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees and Materials Professional Fees and Materials
Covered in full* Up to $210 00*
Elective- Contact lenses for other than Visually Necessary circumstances
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees— and Materials Professional Fees and Materials
Up to $200.00 Up to $125.00
*Subject to Copayment
**Additional discount applies to Member Doctor's usual and customary professional fees for
contact lens evaluation and fitting(see section on Additional Discounts below).
-26-
r-
ADDITIONAL DISCOUNT
Each Covered Person shall be entitled to receive a discount of twenty percent (20%) toward the
purchase of additional complete pairs of prescription glasses (lenses, lens options, and frames)
from a Member Doctor. Additional pair means any complete pair of prescription glasses
purchased beyond the benefit frequency allowed under this Plan.
Additionally, Covered Persons shall be entitled to receive a discount of fifteen percent (15%) off
Member Doctor professional fees for elective contact lens evaluations and fittings. Discounts are
applied to the Member Doctor's usual and customary fees for such services and are available
within twelve (12) months of the covered eye examination from the Member Doctor who
provided the covered eye examination Contact lens materials are provided at the doctor's usual
and customary charges Additional discounts noted on this schedule are subject to change as
deemed appropriate by VSP with prior notification to the Group.
LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual problems that
are not correctable with regular lenses and is subject to prior approval by VSP Consultants.
MEMBER DOCTOR NON-MEMBER
BENEFIT BENEFIT
Supplementary Testing Covered in Full Up to $125.00
Complete low vision analysis/diagnosis which includes a comprehensive examination of
visual functions, including the prescription of corrective eyewear or vision aids where indicated.
Supplemental Care Aids 75% of Cost 75%of Cost
Subsequent low vision aids as Visually Necessary or Appropriate.
Copayment for Supplemental Aids: 25%payable by Covered Person.
Benefit Maximum
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
NON-MEMBER PROVIDER BENEFIT
Low Vision benefits secured from a Non-Member Provider are subject to the same time limits
and Copayment arrangements as described above for a Member Doctor. 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 Doctor in similar
circumstances. NOTE There is no assurance that this amount will be within the 25%
Copayment feature.
-27-
EXCLUSIONS AND LIMITATIONS OF BENEFITS
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered
Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses,
and the Covered Person will pay the additional costs for the options.
• Optional cosmetic processes.
• Anti-reflective coating.
• Color coating.
• Mirror coating
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
• Oversize lenses.
• Progressive multifocal lenses.
• Photochromic lenses; tinted lenses except Pink#1 and Pink#2.
• UV (ultraviolet)protected lenses.
• Certain limitations on low vision care.
• A frame that costs more than the Plan allowance
• Contact lenses (except as noted elsewhere herein).
NOT COVERED
There is no benefit for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing; plano lenses (less than
a f 38 diopter power); or two 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;
• 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-
An Eyec Plan
With You In Mind
Are you seeir_ besK Or are
you simply used to t, view? W&r 00(j
P Your eyecare benefit is brought to you by City of
vision, your expery n-s are cdec, kj!. Kent and VSP
Sharpe,r Rnqhter Your Coverage frorn a VSP Doctor
I
Besides � -iping yo_a ,i� oc ,r),Mne Exam covered in full....... .....every calendar year
Prescription Glasses
r"ye exarm can defect , nurnber of serif_j� health r,(-,, editions Lenses covered in full. .............every calendar year
such as gVj,j(,orno, cotofocts and diabetes, Even n, rer, Plus, e Single vision, lined bifocal and lined trifocal lenses
9 Polycarbonate lenses for dependent children
eye exams for kids can spot problerm that can imp,-,'` learning Frame .... every other calendar year
and development a Frame of your choice covered up to$ 105 00
* Plus, 20%off any out-of-pocket costs
New patients always welcome. -OR-
Contact Lens Care..... ...... every calendar year
VSF1 ,i_to-ork docl�Ors are When you choose contacts instead of glasses,your
located right where you $200 00 allowance applies to the cost of your contacts
and the contact lens exam(fitting and evaluation) This
-9 need them close 3f= exam ism addition to your vision exam to ensure proper
fit of contacts If you choose contact lenses you will be
work, hoine and shsp,,,� eligible for a frame 12 months from the date the contact
0,�tra,c Tr ney pi ov,cle
ir lenses were obtained
3i-,,i1 and offer Current soft contact lens wearers may qualify for a special
frames
0 V�� contact lens program that includes a contact lens
evaluation and initial supply of replacement lenses Learn
and contact to
more from your doctor or vsp com
choose ,cn `)t one Extra Discounts and Savings
.-,DnvenIenfl,.,cohn T[-,,wir
Laser Vision Correction Discounts
Prescription Glasses
Is important. setvice grows w,c yr)u c, ;tj - Up to 20%savings on lens extras such as scratch
resistant and anti-reflective coatings and progressives
vour family for a Vefim(_3 e 20%off additional prescription glasses and sunglasses*
of C ulre Contacts*
- 15%off cost of contact lens exam(fitting and evaluation)
No ID cards, No claim forms, Easy as 1, 213- Available from the same VSP doctor who provided your eye
exam within the last 12 months
VSR network doctor at vsp.com of Cri;, 800-87 7-i 195, Your Copays
2 Make kin appointment and tell the doctor you are a Exam......................... ............................... $000
VSP rnembet Prescription Glasses... ................... .......... $25.00
Contacts ......................... No copay applies
' 1�ou,doctor on,,,:t VSP will hcndle the rect Dollar for dollar you get the best value from your VSP benefit
when you visit a VSP network doctor If you decide not to see
Visit vsp.com today, a VSP doctor,copays still apply You'll also receive a lesser
benefit and typically pay more out-of-pocket You are
irnportanj 2 need<)�, wvt riing required to pay the provider in full at the time of your
appointment and submit a claim to VSP for partial
ap(??ointment? I Meresled it i (i ;_4JCtor whc L e--on sports reimbursement If you decide to see a provider not in the VSP
eyewect or children Wunt c), -,nfine Sava)Q_s sio,�errent after network,call us first at 800-877-7195
Out-of-Network Reimbursement Amounts.
You VIA <1 VSP d-1(,-toT') for Exam Up to$45 00
information c�i, ",nditions of the eye') Ar Lenses
Visit MXom, 'You'll like what you see. Single Vision Up to$42 00
Lined Bifocal Up to$72 00
f Lined Trifocal Up to$82 00
Frame Up to$45 00
Contacts Up to$125 00
VSP guarantees service from VSP network doctors only
Z � In the event of a conflict between this information and
your organization's contract with VSP, the terms of the
contract will prevail