HomeMy WebLinkAboutHR14-327 - Original - VSP - Group Vision Care Plan Number 12229020 - 01/01/2018 Kecords Ma,
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CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to the City Clerk's Office. All portions are to be completed.
If you have questions, please contact the City Clerk's Office at 253-856-5725.
Vendor Name: VSP Vi l n cn6, I tit
Vender Number:
JD Edwards Number
Contract Number: H V-1L4 -- 70 0 -
This is assigned by City Clerk's Office
Project Name: 1I ✓"i CSC a ' r
Description: El anterlocal Agreement 7 Change Order ❑ Amendment Z Contract
El Other:
Contract Effective Date: 1✓1/18 Termination Date: 12/31/2020
Contract (Renewal Notice (Days): 60, dams
Number of days required notice for termination or renewal or amendment
Contract Manager: Laura Horea Department: HR
ContractAmount: $56,10O for a 3 year contract
Approval Authority: F-1 Director [:1 Mayor Z City Council 1]_/21117 Meeting Date
Detail: (i.e. address, location, parcel number, tax id, etc.):
•
January 9, 2018 VSP.
1-'r.s
DOUG EVANS
R.L. EVANS COMPANY,INC.
3535 FACTORIA BLVD SE STE 120
BELLEVUE,WA 98006-1293
RE: CITY OF KENT,GROUP#12229020
JANUARY 1,2018 DOCUMENTS
Attention Doug Evans:
Enclosed are the JANUARY 1, 2018 documents for the above-referenced Client.
Please retain a copy of the documents for your records and forward the additional copy directly to the group.
This new document supersedes any existing document your client has with VSP. If you have any questions,or need
additional information, please do not hesitate to contact us at 800-216-6248, and a VSP representative will assist you.
Enclosures
These documents are intended only for the client to whom they are addressed and may contain confidential information.If you are not the intended recipient(or the
person responsible for delivering it to the intended recipient)and have received these documents in error,please notify the sender immediately by telephone,and
destroy or delete these documents.
0
0
VS
VSP VISION CARE, INC.
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, 2018
Plan Term THIRTY-SIX(36) MONTHS
Premium 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 administrative fees and other amounts due as, herein provided, VSP VISION CARE, INC, ("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.
Kate Renwick-Espinosa, Preside
By:
V '�A
Title:
Date:
VSP-GVCP-ASP-5/07 01/09/18 Ank
TABLE OF CONTENTS
I. DEFINITIONS.............................................................................................................. 1
II. TERM,TERMINATION,AND RENEWAL................................................................... 3
III. OBLIGATIONS OF VSP.............................................................................................. 4
IV. OBLIGATIONS OF THE GROUP................................................................................ 6
V. OBLIGATIONS OF COVERED PERSONS UNDER THE 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
SCHEDULE OF BENEFITS........................................................................... 19
SCHEDULE OF BENEFITS............................................................................27
EXHIBIT B
SCHEDULE OF PREMIUMS......................................................................... 35
ADDENDUM
ADDITIONAL BENEFIT-DIABETIC EYECARE........................................... 36
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 be 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.
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.
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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 Group to signify the
Group's intention to have its Enrollees and their Eligible Dependents 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.
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.
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II.
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 terminate 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: Either party may terminate the agreement upon a sixty(60)day advance written notice.
Group agrees to pay all Claims Amount and Administrative Fees for 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.
3
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 Member Benefit Summaries for Covered Persons. Such
Member Benefit Summaries 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, 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 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. 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
4
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.
3.04. 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 Provisions may obtain a
copy of the Notice of Privacy Practices by contacting VSP's Customer Service Department or by visiting VSP's Web site at
www.vsp.com and clicking on the HIPAA link.
3.05. 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 in trust by VSP.
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
6
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.
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.
7
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. Comments 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.
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 three hundred sixty-five (365) days of the date of service. VSP reserves the
right to reject such claims which are filed more than three hundred sixty-five(365)days after the date of service.
Failure to submit a claim within three hundred sixty-five (365) 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
8
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 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 (180) 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:
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
state and federal laws and regulations and shall include the specific reasons for the determination.
9
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)) [29 U.S.C. 1132(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 dependent
coverage are:
(1)the legal spouse of any Enrollee, and
(2) any unmarried child of an Enrollee, including any natural child from the moment of birth, 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 and who has not yet reached the end of the
month in which they turn age of 26 years
(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 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
11
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 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, o r
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 newborn 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.
12
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 to the
parties to this Plan, VSP shall make the statutorily-required continuation coverage available based on the eligibility
information provided by the Group.
13
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.
14
Vill.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 in 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.
15
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 th e
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 judgment. VSP does not itself
directly furnish vision care services or supply materials. Under no circumstances shall VSP or Group be liable for the
negligence, 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.
17
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.
18
EXHIBIT A
VISION SERVICE PLAN
SCHEDULE OF BENEFITS
Signature Plan
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$25.00 payable at the time the materials are ordered. However, the Copayment for materials shall not apply
to elective contact lenses.
PLAN BENEFITS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
VISION CARE SERVICES
Eye Examination Covered in Full* Up to$ 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.
19
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 1st,
Frames Covered up to Plan Up to $ 45.00*
Allowance*
Available once every other plan year beginning on January 1st.
*Less any applicable Copayment.
Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK,or Custom LASIK patients.
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.
20
CONTACT LENSES
Contact lenses are available once every plan year 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.
Necessary-
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered
Person's Member Doctor or Non-Member Provider. Prior review and approval by VSP are not required for Covered Person
to be eligible for Necessary Contact Lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees and Materials Professional Fees and Materials
Covered in full* Up to$210.00*
Elective-
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
**15%discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation
and fitting.
21
LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with
regular lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER 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.
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.
22
EXCLUSIONS AND LIMITATIONS OF BENEFITS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional
limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by
calling VSP's Customer Care Division at(800)877-7195.
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 or frames, and the Co vered 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.
• Polycarbonate lenses.
• Photochromic lenses,tinted lenses except Pink#1 and Pink#2.
• Progressive multifocal lenses.
• 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; piano lenses(less than a± .50 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.
23
PLAN BENEFITS
AFFILIATE PROVIDERS
GENERAL
Affiliate Providers are providers of Covered Services and Materials who are not contracted as Member Doctors but who
have agreed to bill VSP directly for Plan Benefits provided pursuant to this Schedule. However,some Affiliate Providers
may be unable to provide all Plan Benefits included in this Schedule. Covered Person should discuss requested services
with their provider or contact VSP Customer Care for details.
BENEFIT PERIOD
A twelve-month period beginning on January 1 st and ending on December 31 st.
COPAYMENT
There shall be no Copayment for the examination. If materials(lenses and frames)are provided, there shall be a $25.00
Copayment payable at the time the materials are ordered. The Copayment shall not apply to Elective Contact Lenses.
COVERED SERVICES AND MATERIALS
EYE EXAMINATION-Covered in full*once every 12 months**
Comprehensive examination of visual functions and prescription of corrective eyewear.
LENSES-Covered in full*once every 12 months**
Spectacle Lenses(Single, Lined Bifocal, or Lined Trifocal )
FRAMES-Covered up to the Plan allowance*once every 24 months**
CONTACT LENSES
ELECTIVE
Elective Contact Lenses are covered up to$200.00 once every 12 months**
The Elective Contact Lens allowance applies to materials only.
NECESSARY
Necessary Contact Lenses are covered up to$210.00*once every 12 months**
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered
Person's Doctor,
Contact Lenses are provided in place of spectacle lens and frame benefits available herein.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
24
LOW VISION
Professional services for severe visual problems not correctable with regular lenses, including:
Supplemental Testing: Up to$ 125.00t
-Includes evaluation, diagnosis and prescription of vision aids where indicated.
Supplemental Aids: 75%of Affiliate Provider's fee up to $1000.00t
tMaximum benefit for all Low Vision services and materials is$1000.00 every two(2)years and a
maximum of two supplemental tests within a two-year period
Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's
Doctor.
25
EXCLUSIONS AND LIMITATIONS OF BENEFITS
1. Exclusions and limitations of benefits described above for Member Doctors shall also apply to services rendered by
Affiliate Providers.
2, Services from an Affiliate Provider are in lieu of services from a Member Doctor or a Non-Member Provider.
3. VSP is unable to require Affiliate Providers to adhere to VSP's quality standards.
4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to
purchase a membership in such entities as a condition of obtaining Plan Benefits.
26
EXHIBIT A
VISION SERVICE PLAN
SCHEDULE OF BENEFITS
Signature Plan
Child Age 0-19
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 payable by the Covered Person to the Member Doctor at the time services are rendered.
PLAN BENEFITS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
VISION CARE SERVICES
Eve Examination Covered in Full' Up to$ 999.99*
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.
27
VISION CARE MATERIALS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Lenses
Single Vision Covered in full* Covered in full*
Bifocal Covered in full* Covered in full*
Trifocal Covered in full* Covered in full*
Lenticular Covered in full* Covered in full*
Available once every plan year beginning on January 1st.
Frames Covered in full* Covered in full *
Available once every plan year beginning on January 1st.
*Less any applicable Copayment.
Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK,or Custom LASIK patients.
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.
Lens Options
Anti-reflective coating Covered in full Not Covered
Scratch coating Covered in full Not Covered
High Index Covered in full Not Covered
Blended lenses Covered in full Covered in full
Color coating Covered in full Not Covered
Mirror coating Covered in full Not Covered
Laminated lenses Covered in full Not Covered
Oversize lenses Covered in full Not Covered
Polycarbonate lenses Covered in full Not Covered
Progressive lenses Covered in full Covered in full
Tinted/Photochromic Covered in full Covered in full
UV(ultraviolet) protected Covered in full Not Covered
28
CONTACT LENSES
Contact lenses are available once every plan year 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.
Necessary-
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered
Person's Member Doctor or Non-Member Provider. Prior review and approval by VSP are not required for Covered Person
to be eligible for Necessary Contact Lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees and Materials Professional Fees and Materials
Covered in full* Covered in full
Elective-
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees**and Materials Professional Fees and Materials
Covered in full Covered in full
*Subject to Copayment
**15%discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation
and fitting.
29
LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with
regular lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER 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.
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.
30
EXCLUSIONS AND LIMITATIONS OF BENEFITS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional
limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by
calling VSP's Customer Care Division at(800)877-7195.
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 or frames, and the Covered Person will pay the
additional costs for the options.
• Optional cosmetic processes.
• Cosmetic 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; piano lenses(less than a ± .50 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.
31
PLAN BENEFITS
AFFILIATE PROVIDERS
GENERAL
Affiliate Providers are providers of Covered Services and Materials who are not contracted as Member Doctors but who
have agreed to bill VSP directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers
may be unable to provide all Plan Benefits included in this Schedule. Covered Person should discuss requested services
with their provider or contact VSP Customer Care for details.
BENEFIT PERIOD
A twelve-month period beginning on January 1st and ending on December 31st.
COPAYMENT
There shall be no Copayment payable by the Covered Person under this Plan,
COVERED SERVICES AND MATERIALS
EYE EXAMINATION-Covered in full*once every 12 months**
Comprehensive examination of visual functions and prescription of corrective eyewear.
LENSES-Covered in full*once every 12 months**
Spectacle Lenses(Single, Lined Bifocal, or Lined Trifocal)
LENS OPTIONS
Anti-reflective Coating-Covered in full once every 12 months**
Mirror Coating-Covered in full once every 12 months**
High Index-Covered in full once every 12 months**Scratch
Coating-Covered in full once every 12 months**Polycarbonate
Lenses-Covered in full once every 12 months**
Progressive Lenses-Covered in full once every 12 months**
Photochromic-Covered in full once every 12 months**
UV(ultraviolet) protected-Covered in full once every 12 months**
FRAMES-Covered up to the Plan allowance*once every 12 months**
CONTACT LENSES
ELECTIVE
Elective Contact Lenses are Covered in full once every 12 months**
The Elective Contact Lens allowance applies to materials only.
NECESSARY
Necessary Contact Lenses are Covered in full *once every 12 months**
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered
Person's Doctor.
Contact Lenses are provided in place of spectacle lens and frame benefits available herein.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
32
LOW VISION
Professional services for severe visual problems not correctable with regular lenses, including:
Supplemental Testing: Up to$ 125.00t
-Includes evaluation, diagnosis and prescription of vision aids where indicated.
Supplemental Aids: 75%of Affiliate Provider's fee up to$1000.00t
tMaximum benefit for all Low Vision services and materials is$1000.00 every two (2) years and a
maximum of two supplemental tests within a two-year period
Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's
Doctor.
33
EXCLUSIONS AND LIMITATIONS OF BENEFITS
1. Exclusions and limitations of benefits described above for Member Doctors shall also apply to services rendered by
Affiliate Providers.
2. Services from an Affiliate Provider are in lieu of services from a Member Doctor or a Non-Member Provider.
3. VSP is unable to require Affiliate Providers to adhere to VSP's quality standards.
4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a
membership in such entities as a condition of obtaining Plan Benefits.
34
EXHIBIT B
VISION SERVICE PLAN
SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE
Signature Plan
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: $9860.68
JANUARY 1, 2018—JANUARY 1,2019
ADMINISTRATIVE FEE: $2.11 PER ELIGIBLE ENROLLEE
JANUARY 1,2019—JANUARY 1,2020
ADMINISTRATIVE FEE: $2.37 PER ELIGIBLE ENROLLEE
JANUARY 1, 2020
ADMINISTRATIVE FEE: $2.63 PER ELIGIBLE ENROLLEE
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.
35
ADDENDUM
VISION SERVICE PLAN ADDITIONAL
BENEFIT RIDER DIABETIC EYECARE
PLUS PROGRAM
GENERAL
This Rider lists additional vision care benefits to which Covered Persons of VISION SERVICE PLAN("VSP")are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein or in the Schedule of
Benefits with which it is associated. Plan Benefits under the Diabetic Eyecare Program are available to Covered Persons
who have been diagnosed with type 1 or type 2 diabetes and specific ophthalmological conditions.This Rider forms a part
of the PLAN or Evidence of Coverage to which it is attached.
ELIGIBILITY
The following are Covered Persons under this Plan, pursuant to eligibility criteria established by Client;
• Enrollee.
• The legal spouse of Enrollee.
• Any unmarried child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of
placement for adoption with the Enrollee, or other child for whom a court or administrative agency holds the Enrollee
responsible.
Unmarried dependent children are covered up to age 19, or to age 26 if full-time students.
A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of
self-sustaining employment because of mental or physical disability, and chiefly dependent upon Enrollee for support and
maintenance.
36
PROGRAM DESCRIPTION
The Diabetic Eyecare Plus Program ("DEP Plus") is intended to be a supplement to Covered Person's group medical plan.
Providers will first submit a claim to Covered Person's group medical insurance plan, and then to VSP. Any amounts not
paid by the medical plan will be considered for payment by VSP. (This is referred to as"Coordination of Benefits" or"COB."
Please refer to the Coordination of Benefits section of Covered Person's Evidence of Coverage for additional information
regarding COB.) If Covered Person does not have a group medical plan, providers will submit claims directly to VSP.
Examples of symptoms which may result in an Covered Person seeking services under DEP Plus may include, but are not
limited to:
• blurry vision • trouble focusing
• transient loss of vision • "floating"spots
Examples of conditions which may require management under DEP Plus may include, but are not limited to:
• diabetic retinopathy rubeosis
• diabetic macular edema
REFERRALS
If Covered Person's Member Doctor cannot provide Covered Services, the doctor will refer the Covered Person to another
Member Doctor or to a physician whose offices provide the necessary services.
If the Covered Person requires services beyond the scope of DEP Plus, the Member Doctor will refer the Covered Person to
a physician.
Referrals are intended to insure that Covered Person receive the appropriate level of care for their presenting condition.
Covered Persons do not require a referral from a Member Doctor in orderto obtain Plan Benefits.
37
PLAN BENEFITS
VSP NETWORK DOCTORS
COVERED SERVICES
Eye Examination: Covered in full after a Copayment of$20.00.
Special Ophthalmological Services: Covered in Full.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
The Diabetic Eyecare Plus Program provides coverage for limited, vision-related medical services. A current list of these
procedures will be made available to Covered Person upon request. The frequency at which these services may be
provided is dependent upon the specific service and the diagnosis associated with such service.
NOT COVERED
1. Services and/or materials not specifically included in this Rider as Plan Benefits,
2. Frames, lenses, contact lenses or any other ophthalmic materials.
3. Orthoptics or vision training and any associated supplemental testing.
4. Surgery of any type, and any pre-or post-operative services.
5. Treatment for any pathological conditions.
6. An eye exam required as a condition of employment.
7. Insulin or any medications or supplies of any type.
8. Local, state and/or federal taxes, except where VSP is required by law to pay.
DIABETIC EYECARE PROGRAM DEFINITIONS
Diabetes A disease where the pancreas has a problem either making,or making and using, insulin.
Type 1 Diabetes A disease in which the pancreas stops making insulin.
Type 2 Diabetes A disease in which the pancreas either makes too little insulin or cannot properly use the
insulin it makes to convert blood glucose to energy.
Diabetic Retinopathy A weakening in the small blood vessels at the back of the eye.
Rubeosis Abnormal blood vessel growth on the iris and the structures in the front of the eye.
Diabetic Macular Edema Swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the
macula.
38
REQUEST FOR MAYOR'S SIGNATURE
KE S T Print on cherr w-Colored Paper
Routing Information:
(ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPARTMENT)
Approved b'y Director
Originator: Laura Horea Phone (Originator): 25 .856.5 90
Data Sent: / 1/18 Date Required: 2/ 6/18
Return Signed Document to: Laura Horea Contract Termination Date: 1 / 1/ 0 p
VENDOR NAME: Date Finance Notified:
VSP (Only required on contracts 09/ 8/17
20'000 and over or on an Grant
DATE OF COUNCIL APPROVAL: 11/ 1/17 Date Risk Manager Notified:09 2$ 1
Re aired on Non-CityStandard Contracts A r ements
Has this Document been Specuficall Account Number:
Authorized in the Bud yet? • YES NO
Brief Explanation of Document:
VSP Administrative Services Contract - Vision plan
AH Contracts Must Be Routed Through The Law Department
(This area to be pleted by the Law Department)
Received: 0
Approvai of Law Dept.:
Law Dept. Cor�aments - �'
Cute Forwarded to mayor:
Shaded Areas To Bpi60!n
feted By Administration S
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Rec ived I j����
Recomfitmendations and Comrments
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