HomeMy WebLinkAbout0423.0944 City of Palo Alto
City Manager's Report
TO: HONORABLE CITY COUNCIL
FROM: CITY MANAGER DEP ARTME1'o'T: Human Res<>ur«o
AGENDA DATE: Sep\>!mber 12, 1994 CMR: 423:94
SUBJECf: Renewal or Contract "ith Visioo Sen-ke Plan for City Employees'
Vision Care Servkes
Jl.F.&lI!1£I
The City Council is being a~ked lo appr()vc the 194--i-·Q5 \'i~il)jl C cl.re' S-c-n l:..',: PlJ.n. rae\\J.!.
The ()ne~year renewal provides fl1r 3 to.5 pt'r..::t'l1t prfmium lr..::tt'3.>;'~, reSUff!l\1::. frt1l1\ an
incre85e. in paid claims.
MCOM.MENDATlOhli
This report recomm~nd5 rcm'\\'aJ of m::: cOnlrJ.\.'I 1,1,'ltl1 Vi~:I'n St'r,'t'>: Pl3..r! rySP) fnr imuIoJ
vision care ser.'ices for City employees as conwine-d in tf,c COlitt'li \'(;, h.arg:.J.ining 3gT~cm~ras
POLICY IMPLICATIONS
Acceptance of VSP's 1994·95 renewal would contim.lt !he vislr;n C2fe ki'ICfLt.s, 3..!i. (:or:~ined
in the collective bargairting agreements,
EXECunyE SUMMARY
The City of Palo Alto nrsl provided vision care benefits under an insurance C(ln'nct
underwritten by VL,ion Service Plan (VSP) in 1987, as a resull of co!lectiv" b.argalning
agreements with City employees. The bargaining agreeme-nts provide ror maintaining
benefits equivalent to Vision Service Plan's $20.00 deductible Plan A, wi!h the monthly
premiums paid by the employer,
The plan is an "experience-rated" insured policy underwrillen by VSP ,n which !he City
pay5 the toral cos! of all incurred claims, plus the insurt!r') rewmil1n, Sinc-e 1987. prtrnium<;
have renlaiued reiatively stable, incre3-~ing at an ammaL rate l)f a-,pproximztely 2.5 percent
per year.
In March 1994, VSP requested a rate increase of 26 perC<:nt f,or the 1994-95 poile) )""-'.
based on increa.sed utilization and inflation, After di~ct.lssions with VSP, they agreed to
reduce the re4ue-sted increase from 26 pelcent to 11) pe-IccnL
Page 1 of 2
--. ..,..,-t-" 'r
\
Staff investigated rhe fea,ibilir; of self-funding the risk, hUI it was delennined Out self
fuDding would actually be more co,tl)'.
Scaff also investigat<:d other competitive vision care plans. No"e of the oilier insured pl=
offers a network of providers which adequa~ely covers the residency areas of City
employees. We are currentJy working with PERS to de"\"elop a statewide vision care plan
whkh may reduce costs in tbe future.
FISCAL IMPACT
The current annual premium is $84,{)(Xl The one year renewal pro\'ides fOT ;3; 10.5 percent
premium increase resulting from increased utilization and paid claims. TIle total J.nm.Ldi
increase in premium would be $8,200, for a lOlalannual premium of S92,2C~1. funding is
available in the 1994-95 Genend Be:neflis Intern21 ServI(;e Fund to cover this. in(rt':J.sc.
/}..i'.'YJRQNlItENTAL ASSESS1tiE~'1
None. This is not a ~pmject" for puq)(lSI:" of rhl';' Caliiomia Envirnnrneo!al Qualily A';::L
g.1'T.ACIIM¥1IT"s
Short Fonn Agreement with VSP
VSP Mas\er Policy
PREPARED BY: . Leonard Zucker, MiJlager of Employee Benefit;
{' .
DEPARTMENT HEAD REVlEW: / Icc ~ CJ2_· -S,~_
JA~C .. OUNDS
CITY MANAGER APPROVAL:
CMR:423:94
--------------- -
Page 1 or 2
\
~ AGREEMENT No. __ _
(
[),I,H TO BE. ENTf;RED BY THIS AGREEMENT MAOt AND nmRED ".ITO ON 1'"H~ ___ ._. __ •. ________ ~ ____ OilY Of" ________________ 1';_ BYCrT'T' ~Uflc.t'AS#>Ir,;.
EJY J.Hi) 1!IfTW(fN TI* CrTY OF PALO AI.TO 1~E"F!f. ....... .::_rE~ F!E~ERAE:O TOAS CITY. ArlD
~III: YJs.tQnm..se..rrJce plan __ ~___ !2,
,A')C'II'I£S$; _~-)JJ ___ .Q.~.aJ j ty Orj ye ~CI1Y, Rancho Cordov~~':Z1"1 ~ __ ,P~E! ____ _
!ME~"THI AE~ WAS CONTRACTOR) I'. CO/'ISICER.'.1'"1ON or THEIR ~lITlJAL CO'\'tNANT$. TI'i[ p;"A7rrs flE"RETO.l\GAt:~ AS FOUOW'S
• CONTRACTOR sw.u. PAOV1Oe or. ~NISH r",E FO<.Lowm S!>EClF IHl SEA.~ :CES. A.~D''C'" .,. .... ;E~IA'..$ SF-tCfF!Ell ~ EX"iJBlT S A and e
"n4C!-lf['l HE'RETO "-"'0 HC~TE"D ",EFlErN 8'1' ~IS R.E:.Ft;:RI:.NCE
~lsion care ~oyerag~ for eiiglble City employees and their e~igibJe depe~d€nts.
Exhibit A REnewal Notice and Re'lisions to Contract
Exhioit 8 -Vision Service Plan retroactiv~lY to. and
• TERMS rr-': ~'" {QS ~ 'OR W;THliALS FUCI'IIlSflE.P LINDeR DII~ MiRf" Ito< E}(T S~"u. C~~liC;: 01'1 . .in C I UI:L~JlJ.L.J .. 1 .t~L
.u.r:.>~UBiC()l,/i~'.ftHlt',EFOf\E __ J~n~_-1~9_5 ______ _
• COMPENSA nON For, ME n.r.L f'c><;cm.t"",::f C,;-Tt-':S A"Rff'-':r-,'1' ex C~T'{:;'>-I,,:.,P,l,~'ca-,J>.:I.CTCf1 $3.37/rr1onth for each indfvidvill eligiDle €j:1;Jlo)ye,~, and
SlO.OO/~onth for each eligib12 depelldent, in 0ccordance wlth
C-:' .... i'rW:r,::": ... A~).PUC,n-Exhibit "8 1', Not t<J exceed $£'2.20[1 per y';ar,
• GENERA.L TERMS AND CONOmONS AH:, INCUJDE'.:)CN BOTH SlOES OF T,,:S DOCiJ;'iE~IT
THiS. 4GflE-€ME!'O! SHML f>ECOIAE HHCTI.'i UPO~ ITS APjl~CW\l A.1D f;(ECUTIQ" 81' em. 1'< WIINfSS; THEREO~. tHE PARTIES H~\iE EXf~UTED TtflS
,I,GJUlMfNT T~ [l).1", W')f(i'rl. NiO V-tJ,R FIRS'!' 'foI'f;lmti AMYl:
1Cl..G HAltl!a.f$:S. CClf(TRACTOF.1lljj1M!i ~ 11ldEm.""o'Ioj , ~Iend aM n~ ~rm~ Cln', its otilU~, l!;IeIlts. a1~ emplD'/teS Ir"rn .. r.l' a~d aJl ~~.Ljs. ~;;,s or 1.aMIty [)I"
.any rl&bJrt, -.",..,o..""q 1IIf()t~~::SM'n, ..a1Se(jb): Or ,ar.:;.mQ Olll ~ GOU1ID.Cl{1'Fl'S. ~$ \l!!!~T'!;', a\le~1S' or ~m>,l~s "~IIQt>'ll a:I~. erJo~ Oi cm,,~ns Ol w;lttu'
~, (II «lOOOO' Ie!' wt101 t!'1I! taw 1o'?1;lO$tS 'Wl!:I1Ia~irt), on CQ,\jTAACTCi1 Ito ~ per1"rmance or 1.liu;e t~ ~r1cmTl ml& a;~mt!'lt OJ' CQ'1'JRA[;lOFi mw A6IUDIIEJIT. Tl'.;:s ~~ aoGJtlleo'!j5 and ~001l1¢ Q!) 't1e rere'S· Dew rwr~nt tlie Mtlr~ 2~ reemertt ~Iween tI1E p.attJes w+ttJ ~Pf\.1 to ~ p.,.:chut
iti1d ale tJllhe e!)j,apmetl" malena/$ Gr SI..~ 01 p.a:y-mtnllor $eMCr.; whiCh mz)' tie 1m: ~ub]tCt 01 Iflo$ corrtract .AI I pm,;r aQrfl(T"~!" r~pr~"(If'S, SbtcmI!nts,
~aNl~g:s~orari)l'.iml~n~r-= ~~~~llerel1,o'
• PROJECT MANAGER Ah"D RE?ReSEPiTATIVE FCA em
....... leonard ZY.tl.er _____ _
Humar'T Resourc:e~ --'=
P.O BOX 10<:5(1
i'",w ALTO, f f\ 943.03 T~415) 329-2235
• INVOlctNG Si:NOAU II'NCJrCES TO rHo. CIW, ATTN ~fiOJ<:ClIO,NA"U'l j
• CITY OF PALO ALTO APPROVALS: ,ROUTE FC'fl SKiNAlU~t:.S ACCORDI<'IC TO !\I,IM8;:AS IN A,P.?RO'IAL E!OX"S =:>EWW,I
('
"-,
,:;;'.'''--
--, vsP I !lElo<"EW AI, NonCE
I April 2'.1, 1m
, .... ,. _____ ,_,r-:;-',~
VL,",IU~ SEHVlCE P'LA..,",
I I mY OF PAUJ ALTO
, PO 80. 1 ()1jO
Palo Alto, CA "-13m
ATIrNIlON: Jay &'UJ>ds, DiT"""r Pc"""""i
Your VSP .. isi{XI :;are c'~ri~ has been re\·iewed in amidpatioll of th.e upcoming n:ne-,',ra.L As a result
of thi! 3lUlyru. F~ur r;il~ and renewaJ period hJ.ve be-en 1'e'~'lsed .as foUows.:
GROD' 1<A:'.r£:
GROFP ,:
RE!\,"£\\'AL PERIOD!
Cl1U<E."'-T RATE:
~T.W RATE;
ACCOt-:>., EX£CLTIVI:
rr~£PflO,,'E .'.l':'>lBF:R:
C1D' OF PALO ALTO
OOW)51l
klv 1, l~..f~J~.m(', 30, lS9')
-5) ,'05.14. 80~ 5' .0,,1 lO. "~S
S3.37,:''';.80/lO,tJJ!1O_ \5
$1.1\:: ?d;.'j('!', Dim1(t ~falJ.'lg.:-r
t,sO'J) 367·9618
To .l~ccpt this rene'Jo'al, ple..a..sc: ~lgn and return ~ botwm portion of Lh.i~ no!ice. Benefil forms are
oonnaliy \.',WeI for sixtj" da)'j.. Due to It.e pending ~ne';lr'al\ aU benefit fonns will expiIe a.i rhe end of
the current l;ootrJet period. No further benefit forms wlli b<" is)ued after the renewal da!e unrtl
confirmation is m:~i\,eti.
Vision SeIYict Pfan appreciare~ yOlJr busille$s an,j $trives. to pro\'iJe complet(", sati:,facUcn with our s.ervice.
If yoo n."e an)' qlle-stions. or l,Io;i::.n to w.s.:'J55 t.!\is. rent:-'.\al notice, please c'.mtact your VSP Accoont
E.xec:utive.
~*& ••• -•••••••••••••••••••• -••••••••••• ~ ••••••••••••• ~ •••••••••••••••••••••••••••••••••••
Pk::a.sr: sign and n=wm thh portion of the notice in the enclosed envelope to acknowtedge accep-"loBJlce of
tbC' reDi,!l\'a.I.
GltOlJi' :-IA.-.n::
GltOUP I:
RENEWAL PF.RIOD:
RENEWAL RATE:
cc: Len Zucker
crrt OF PALO ALTO
ool025S4
Juiy i. \994-June 30, 1995
53,37/4. 80! 10.00110,55
Auihonzi;J<:rioup Rcpresentauvt': Slgn"."tu"re=---
c/" CITY OF PALO ALTO
P.O. 80_ 10250250 Hamilton Ave,
Palo AIro, CA 94303
I
I
I
(~--
PLE>.SE ATTACH TO YOUR COm-RACT
I REVlSlONS TO CO!'<TRACT
CITY OF PALO ALTO
OO! ()",...584
IT IS HEREBY AGREED .>w elfecti,,,, July I, 1994. "",tract sIl.>!! be revise.!., follows;
COSTS tiNDER THE PLAN
PREPA ~'),!El<rr F"..L<; (?age J i;:
i?ym?l11S b~' Gro,,:) iD VSP tG~ -.;:l',':':'-C'j :d.r.j ,,·.?:ti1.i~ :HQ\ :c;;j :' ::;~1Ii ,!:.J"Iig u':e !I:!ozl
Tem 0;"' the COllir.:i.::: ~:TJ..H ()e 2S f,:,:lD',", " .
The total monthly payments a.."e due irom liie Crro'Jp 0'1 the fir:::1 d2:{ of e-4C~ consec~ti .... e
month, or as mu~ly agreed ';;pon by VSP aJ'l,o Group, OL'10 WI1"!!fi.a gra.::e per,cd of r,ot I~
tI\an l~irty.-one \3l) ~.ys.
Af'-..er the Initial TC'nn of !.he CO.11'-3.;:[, \'SP may, upon Sl\t) {WI da~s pnur wntten notice.
postilie prepaid to Group, cr.a.ngc ihe i!.bo',.'e co~t. pro, idu! Ih~ VS? 5tall >\ot raise th~ cost
more often rhan ('Inc: in an)' t".\ .. ~h'e 02) rnorllh penoo
l -----------------RI
-,
----------
\
· .;
p,xH1BI't' B
-------VISION SEHVICE PlA~
Group Name
Group Number
S tall> of Delivery
VISION SERVICE PLAN
3333 Quality Drh.
Rancho Cordon, California 95670
GROIJP VISION CARE PLAN
CITY OF PALO ALTO
(OOIIll584)
CALlFORNJA Effecti .... e Date JLLY I, !<)9.4
Premium Due D.re nRST D.'" \' OF MO:-ITH Pian rerm D\TIVE (11)
~!o~"TllS
in ccnsiderntion of payment by the Group or the prcm~urr.s .;.~ rerc-ln ~r'J,~d':-J, \"rSiC:-\
hereinafter s.o:! ;011." This Plan i~ delivered in and goyetlled b~' f'.e :a,.q or:..\b.;: Si.J:e (Ii' deJ; ... c~
and is subject 10 the term So and condillcns rcciled on the
pa.'"1: of this Plan.
VSP-{lVCP-12/92
-,-
------=:-:::--;-;-;:-;.~~,,-, Roge; L Valine. Presl'e~t
08i11/94 dd
1.
II.
m.
IV.
V.
VI.
vn.
vrn.
LX.
X.
'VISIo.~ SEH\lCE PL~ ~
VISION SERVICE PLAN
GROUP VISION CARE PLA.'!
TABLE OF CONTENTS
~
DEFlNlTIONli
TERM, TERMINATION, AND RENEWAL
OBUGATIONSOF VSP
OBUGATIONS OF THE GROUP
O!HlGATIONS OF COVERED PERSONS
COVERED UNDER '!HE PIAN
ELlGllill...'TY FOR COVERAGE
CON1Th'UATION OF COVERAGE
~TIONOFD~P~
NOTICES
MlSCEI..LA!Io'EOUS
AUMJIMENIS
EXBIBlT A • SCHEDULE Or BENEFITS
EXHlIIlT B . SCHEVULE OF PREMIUMS
fAQE
4
5
7
9
to
12
\3
14
15
l · J ----------------------------------------~
RPL'i 4193
.-~-.,,-~ .... --
"'ISIOt'" SER"\-'ICE PIAN
VISlOli SERVICE PLA.N
GROUP VISION CARE PLAN
[, DEFThmONS
Key terms used in this Plan are detined and shall ha ..... e the me2ning set forth as follows,
Wllcss the contexi of a rerm's usage clearly requires olhen.1;rise.
1.0!. ANISQt\lrETROPIA: A condition of unequaJ refractive slale for the (WO eyes.
ODe eye requiring a different len! cOrT'e£;tion than the other.
CO2. BE."tEID FOR+'l A form issued by VSP idennfying the individual rl~med
tt~reon :as a Covered Person of VSP, and identifying those Plan Benefits 10 which Covered
nrson is entitJed.
un. .c_Q1S.fl~?\TI;\L MA:I:IIR: All confidential or personal :nforrnail{ln
.:Ot",~mi.ng the medica.l, penonal. fi.na.~,,~i.al or busine~s affairs of Covereci l'ersorls acquired if.
the course (ji pro ..... idin.r:: PI::m Befiefils hereun.:!er.
L04. ~QPA r~.1~:-t.IS An)" amoul1ts required tobe paid b)' or on behalfofa Covered
PetsOr! for Plan Benefits which are r,C,1 fully covered,
1.05. CQVERED PERSON: An Enroltee or E!iglble Dependent who meeiS VSP's
eligibility criteria 3nd ..... ,'ho is cm'e!';!d under this Plan.
1.06. DEDl/(lll1L.E:: An amounl which is paid by or on behalf of a Covered Person
to'llW Pian Benetits. It apphes :separately to the Plan Beneii.rs incurrej by eacn Covered
Penon. P[an Benefits will be paid far only tho~ expenses, services, or matericls which are
more than the deductible amOUr1 t.
1.07_ EliGIBLE DEPENDENT: Any legal depend, .. of an Enrollee of Group who
meets tl";e crite!'U for eligi'='lliry establis:hed by Group ;arid approved by VSP in Anicle VI of lhis
P1at1 ~nder which slJch Enrollee is covered.
l ____________ -_\-________ ~
RPLN ./93
,*,
-----
VISIO.:"l SEHVlCE PI A::,\~ -----
LOS. £.MERGES'" CQWlTl~: A cor;ditlOn which rC',qum~'s the Covered Person
Of Eiigib\.c [')ependc-nts to seek immed:ate ','l!Jon ca.re either from a VSP Member Doctor or
L09. ~QL.ill Art ~m'P:o~et' or memb(or of Grctlp who meets the criiena for
elipbwry speo:ified undo, VI. EUGIBrLm' FOR COVERAGE,
l.iO. ~. Al"l employer or ot..~er entity which conmcts with VSP fer coverage
u.nder mu Plar1 in order Lo jJf(>;'ldc \."Isioo care coverage to it~ Enroilce:s and their Eligible
1.11. GROt'P APPUC ~~_: The form 'SiEGed b:r' 2.rl awrtHm7ed represent.Hive of
wh~ch l~ becom~s 'QiIE)~;I1X',j dllo:!: to J. minrung aJld stre:dling oi 'he iISSUc; in its central are.i.
I. i4. ME\fBf..R DQ:~],.Q.R: An vptometnsl CoT ophL~almQlogist lii,;ensed and
ot.he:r~':5t q\.J..;]lified to pracuce · .. islo!'! care and/or piOv:de ~'is.ion care materials. who has
con~ with VSP to pro\-jde .."is-lon care ~f\'ices ar.d/or visi.:m care maieriaJs en behalf of
Covend ~s of vsp,
l.l~. NO'N.ME.,'\(JER PROVIDER: r\ny optC>fI".et!'ist, opticia..1'\, Qptnhalmciogis.t, or
Ll6. PLAN AD~IlN!S]"lt~IQB: The pe=n 'peciticaJly so de5ignated on the
apptication, Of If a.~ adminl$~.!!O; lS nDt :>0 de5lgnated. 'he Group.
'-----__ -2-__ ~j
RPLN 4/93
.•. ----~._~,. -;"5) ; __
\
,,=-'-__ ,.;......_. _______________ .; ... c',
__ -----"'IS10.", SER'VICE PL\..."
a Covered Person is entitled to receIve by 'o'iitue of cC',<'r.l{2:e ul'1d~r t)'u~ Pla.." as defined in tJ:-e
Senedule of Benefits 3ruched hereto as bJub!t ...\.
1.18. rsEMIL'MS~ The ?ityments made 10 VSP b) or or: b:c"M.a.1t of a Co'''ered :Person
to entitle nim!her to Plan BenefItS, as stated in me Scheduie' of Pn:miur;'js attached hereto as
Exhlbit B.
1.19. RENEWALJM.If:; Tn~ date 01 'J,hkr. ~"le Plan sMIJ rt:1ew. or expire ifpropcr
notice is gi Ve:l.
1.20. SCHEDtl-E O~·EIll;}..:_ The Ccc,H· .... e;;t, i'l'r~c:;l"d r:e:-eiO .l~ [J::"i!)i! A.
~~ _________________ ._J-_________________ /
RPLN .,9)
2.01.
I
-4. j
'-------
RPLN 4i9)
..
(
\ ,
VlSIo.~ SERVICE PI~"\" "'"
lIT. OBLIGATIONS Of I'SP
3.01. CQ"'erue or CO'fered Ptrspns: VSP will enroll for coverage each eligible
Enrollee, and his/he I' Eiigible Depel1dents, jf dependent c.overage is provide.o. aJi of whom shall
be referred to upon meir enrollment as "Covered Persons." To inslitute coverage. Group may
be required by VSP to complete and !iign a Group Application and forward su~h applicaticr1 to
VSP, aloog wlth information regarding Enrollees and E.ligible Dependents, and aU appJicable
p",miums. (Refer to 1'1. ELIGIBILITY FOR COVERAGE fcr funeer c.",Is.)
Following the enrcrllmenl of the Covered Persons, VSP will make available to alJ
Covered Per'Sons a Vision Care Brochure. Such Brochure .,Inn summame the terms. ar;d
cor.ditions set forth in this Plan.
3.02, frovj.siQ!1 oLPJ.i.l1L __ »~IJ!fil:s: Through il5. !'>kmbe: Do(:tors (0; tTHough other
uce~ vision care providers iii C'::.S.~S where a Covered ?t.EO:i d10\.lStS ~o i\:':eiye Plan Bef',euts
from a Nero-Member Prol,'\der) VSP shaH pro\l\d-: Covered hrs.ol'\s SI.iCrl Plan Benefits. hsted ~Il
the Schciute of Benefm. Ex.h.(bit A ~.ereto, a.s may be Visually Ne..:ess.ary or Appropriate,
subject to any limitations, exclusions, dedw.:tibles. or copaymems therein sLlled When a
CO"o'ered Person desires to receive Plan Bendits, the Covered Persor. 5hatl contact YSp, VSP
shall forv.-ard a Benetlt Form to the eligible Cov~red Person, for use if< receiving Plan Benetits
from a Member Doctor, or for reimbursemem when PI311 Benefits are recei .... ed from a Non.
Member Provider. Benefit Farms s.hall be issued [0 Covered Pers-ons by VSP in accordance
with the lateSt eligibility inforrruuion furnished by Group_ Any Berlefil Form so issued by VSP
shall constitute a certification 10 the VSP Member DoctOi thai paymer1! wiil be made, and VSP
shall nat be held liable to Group for any Benefll Forms Issued ir. error. provided they were
issued in accordance wilh these provisions_ Covered Persons are required to obtain the BeneiiT
Form prior to sec:king Plan Benefits only in ~s in which the Covered Person intends 10 seek
Plan Benefits from a Member Doctor (See Seclion 5"03 for further detall,)" VSP shall process
requesto; for Benefit Forms whiCh ~hOl.ll be forwarded w VSP by Covered Persons, Group. or by
the P Jan Administrator. VSP 'hall reimburse .:Iember Doclo" for Plan Benef"s provided '0 )
. ~."-~',
"C,,··, _~":-:;:'
VISKX~ SEHVICE PL~"
Covcnd Persons, or reimburse Covered Persor,s for Pian Befle:I.(S r~.::eived from Non-Member
Providers.. \es.i 3.n~r' :lp?licabte d.edu<~.lbte Q.~ ';Qp<iymenl, within il reasor\ab1e tlm~. but not more
than fOrTy-five-(4S) d.1~~ after VSP has received the completed Benetit Form from e~t,'Jer its
Me:nbet Doctor or CO'o'ered Person >
:UH. DsierminaHpn of "twa! "ecesSih': Plan Beneftts are covered oniy when atld
to the extc\t t:h:u th~y J!t deemed Visually Nece~ or Appropri.are for the proper treatment
of l Coo.--ered. Per$Qn' s coodiuOfl. QuesllCf1s in .... olving necessity or appropriac.enes'S of treatment
1hall be decided by the Mtm'ocr Doctor (or NonrMember Pro .... ider) responsibl~ tor [he Covered
Person's care J1id are 5lJb.iect 10 re .... lew by VS? Any objections ot' (l Co .... ered Person relating
tu sucn cecis:o:"]s rr:J)' ~ m~de to VSP ;l,l the address given hereHI.
the offl .. --es of VSP tor a~}' C(\\e:'cd Pers,)ns v,'no wish to inspe(l or ~opy it. VSP shall provide
to Covered Perso:;s. ar. upd.1teO lis! of the Mem'oer Doctors' f1ames, addres5es, and telephone
3.05. ~ttQn or CQnfide-illia,lJti: VSP shall i'':Oid 1.'1 Strict confidence all
cooF;dential iTwHteTS and exercise its best efforts to prevent any of its employees, Member
Doct<Jrs, or agents, frem disclosing an)' ,'onfldential maner, except to the extent that slJch
Cisclosure is neceJ.5al'Y to enable any of the .above !o perform their obligations. under this Plan,
i"lcludlnjl but not lirni.ed to s.haring information with medical information burea.lJs. or as may
otbenaiise be !'equired by il.w,
CO\:ered Persons may obtain Plan Benefits by contacting a Membt':r Doctor or Non-Member
Provider. Reimbursemc!'ll is stlbjecl to the same provisions as staled eJs.ewnere herein.
·6·
RPLN 4193
•
. ' .
\
---"lSIO."'" !SER' 'ICE FLA. "'i r-rv OR! !Gc\no:ss Of TIlE GROa I 4.01. ldc!!tiCoriuon or Ell&ib!e Enrollm .~n Enrode< " elIgIble lor coverage under
thIS-Plan, if he-'she sa.tlSf:e~ ti:e emollm~f11 cntena Spe-CII;eu tn Para.gr.J.ph 6 Gila} M.:!tor as
nHJ.tuallya,greed to by \rsp ;l,"'d Gro:.:p. B) the ;::f~'¢,;t.i' .. e date of ;."tis P~an. Group shall provit:le
VSP with II Li.sting, U1 a form 3+-""PTUved b)' VSP 0:-JJl oi its Erlroji..:e~ .... ,ho :ue e!igib:e for
~ under this Plan as of lila! date MId 3. d-esignat:on at i.am:ty su.tus for each such
EnroUoe. jf ~t cO\.-e~e u pro""ided Thereaitc:r. Group Sohal I supply to VSP on or
before the last da)' of each :':;Qnt1'l, In il [arm J~rro\:ed o~· VSP :! lis!ing of all Enrollees., 'With
a designation of iamiiy Si..2':l'';. rf! ~ 3dd.:':d t':J ~'r ~.:~e:e-d jrom VSP's ..:-cq=,age rosters (or the
for any CQ"o.-i!1'e.j Person is. ntlt recel\.:d by tIfe ume ~pe.:ltiej a.lxl~'e. VSP resen.'es the right [0
tenninate all righ!.S of sl.!ch Covered Pen.o,., ~d sl:ch righi~ may t< re:n~'..a(.:d only in accurdance
with L~ req uift~ t.5 of this Plan.
VSP may change the premim!'ls shown 00 the OlttaCnea SchedUle of PTemmms, E).hibl.t S,
by giving the Groc~ at l.east .may (60) d4)'s advance ·,.I,:riuen nDIKe. VSP may change the
Premiums at a.ny time: :1'.e Scheduie of f:.er,~{t!s. or .'loy other t.;-m~ .!.nd cor.,dit;ons of (his Pian
are ctlanged. No cf..an,ge will I:'< made during tr.t P!a.!1 Term unless Ihere is a ...:-hange in ttle
s.:lledule of Benefirs or:i ..:h.a.nge in 3..r.y other lerms and conditions of [!ie P~an No change Vt.'lll
be made more ofter. than or.c.e-during <wy twdve (l~1 me-nit· f,<'r.0d l;nl:!~s t~.ere l~:(, -:-hange In
the Schedule of 8enetlLS OJ a changt in <illy olher temu arLd ~ond:u(;n$ ci the Plan.
-7-
RPLN .)/93
.
~.-
-',' .','
\,
''ISIo.~ SERVICE PI ... '-,"
Notwims"",ding me ahove, vSP "'''rves t" nght co Lncre>->e Premlums roqUlrro )
ile",uoder by the amo"", of any taX or asse" Olen ! oot now ,n < trw "hee, " ,u">«i0er,:iI j" i<.'d I
by any ta.'(.lng authority, WhlCr.. IS attnbu~le to ~he PremiUms. VSP r::--:e)'ves from Gro ... rp~ I
4.03, Gns:e Period: Group snaij be ,lilowed J g:-J.,;.-e periN (\{ l.hln~'--ol'le d 1) Ja_n I
DtJri:1& .s.&;d r following the due date for making any paymem of p~mllJmS due ll;":cer t~i~ Plan
grace period, this Plan :;hall remain in ftiil force ;J.."ld etTect for .Ji Co', e-xd PerM.'r1.s ':'-G~ered
nereundtr.
If Group fails fO make art)' payment of premiu.ms due b;. rh~ ~~d (Ii .. ..n~' grace penoo,
4.05. Distribution or Rrouireri Docurnt!1.U~ Group agrees to olslr.b",le;O E_"roilet-s.
any disclosure forms, plan summaries or olher matc:riaJ tIl'U may tx req'.lirw :0 br:: ';t\e-n to plal'l.
subscribers by any reguiatof'l au.thority, Such materials shall ~ di~!nb\'H~ b~' Group' 10
Enrollees no LalOr than thiny (30) day, ait« tne =eipt tl1erroi.
l~ __________ 8_. ______ ~
RPLN 4193
----.
---,"----,--,-.-..'. -.~---,
'VL,",Io."I SEHVICE PLA .. """
y, OBLIGATIONS Qf CQVERED PERSQN.S,J'::QVERED L~UER mE PLAIi.
5.01 ~...mj: By ltti.s Pian, Group makes coverage 3.'r'ailab!e to its Enrollees. and
theiI Eligible Dependent~, if dependent coverage is provided, However. this PLaJ1 may be
amended or terminated by agreemenr bet'n'een VSP and Group without the consent or
concum::nr:c: of the CO'o'ered Persons, This P!an, atld ail Exhibits and an anachments and any
amendments ~reto, shall constitute VSP's sole and en.tire urldertaking to Co\'~red Persons
covered under this Plan,
All persons covered as Covered ?erson!l under this P;an shall have the foilow.~ng
obligations as a condition of their coverage:
5.02. ~&lJ,tljlbles and Copavme..D.tL..[Qr~nke-s Re\:e.ir~_d: WheT;:, as 1[',diC'J.ted en
the Schedule or Benetits. Exl1iblt t\ ilcrelQ, dej~~ctibles and/or copa:m:ei1i) arC' r.::ql'Lred fOT
certain Pian Beneft~s, Illese dN1.LClibles. .lnd/or ,opaymenis. ,hajl be lf1e peisonJ.! r~s~ns~lJiiil~'
of the Covered Person receiving tile care and nlll$t be p3Jd 10 lhe '':iStOjl cal": prO\'ld;:r (wr!.;-~r.el
a Member Doctor or Non-Member Frovtder) on the ddle tlle services are fl!ndered,
5.03. Almr0yal of Scp'ices: A Covered Person mus! recelve approval before visiting
a Member Doc!Or. Su.ci1 ;'1pproval is. re(:eived by obtaining from VSP a Bt>nelil Form. ShDI.!ld
the C'~1Vefed Person receive Pian BenefIts. from a Member DOC!Oj wllhowt such apprma.i, then
for the purposes of those Plan BenefHs provid(,A to the Covered Penon, the pr..:.wic.!er will be
c-OIlsidered a Non~Member Provider, and the ben~flt.3 available wiil be IimJled to those for a
Non-Member Pro'l:'ider.
5,04, CQIDplaints and Grie,'ar.c(ji Time of Action: Covered Persons s[Jall report a,1Y
complaints and/or grievances to VSP at Ihe uldrc:ss given herein. No action In law or In equity
shall be brought to recover on the F'larJ pri(Jr to the ';!;:(puation of sixry (60) days after the Benefit
Form and any applicable invoices have beer. filed with YSP, No such action shaJl bl;': brought
after the expiration of three (3) years from the ~ast date that the Benefil FGrm and any applicable
l.., ___ in_v_o_~_e_s_n_l_aY __ b_'_S_U_bm __ i'_'ed ___ 'O __ V_S_P_'_In __ ac_c_o_rd_a_.~_c_e_W_l_'h __ 'h_e_,_e_rm_,_s_o_r_th_i_s_p_!a_n_. __________ ~~
PLN ..;/93
\
VISIU"'J SERVICE PIAN --------..".
VI. ELIGTBlLID FOR CQVERAGE
6.01. EIjgibflily Criteria: Ir.dhdduals will be a...~pted for coverage hereunder oniy
upon meeting all the applicable requirements .set (OM below.
(a} .£rH:~JJm: To be eligible for coverage, a per~n must:
(1) currently be an employee or member of the Group, and
(2) meet the criteria established in the cov::rage criteria mutually agreed
upon by Group ""d VSP.
(b) fJ..Utible Deoendents: If dependent coverage IS provided, the persons
etigibie (or co\.'er.;.ge as derendeJiIS shan include:
(1) [h~ iL'g~1 S~-oU~F. of any Enroliee, ;"Hid
(2) any unmarned child of an Enroll-=e, including 2ny n~[llral child from
t:,e mCr!1::rH ctbirth, legally adopted cl1i!d from the moment oi placement ~n Ihe resiJence of lhe
Employee, Of other child for whom a court holds the Enrollee responsible; and
IA) (or wno5e support Ihe Enrollee is legally responsible and who
has not yet attained ihe a,f:C of nineleen (19) jeafS. or
(B) who is chierly dependent up<Jf1 lhe f:,tuo:lee for support. has
no~ yei a,uined t'ne age of t'.',enty·slx {26) yean. and is currently l'nfolled as a f!.JlI~lime ~tlJdent
in good sWlding activeiy pursuing a degree or certificate at a re"Cogniled edutationa1 institution.
(3) as further deiined by Group.
rf 2. dependenl, unmarried child prior to attainment at' tile pres:::ribed age for termination
of eligibility becomes, and continues to be, incapable of self~sL..lsraining employment because of
mental or physiQ) dis.ability, that Eligible Dependent'S coverage sha.H nOI terminate so :ong as
he remruns a dependent and the Enrollee's coverage remains in force: PROVIDED that
s.atisr"actory proof of the dependent's. incapaci:y ca.n be furni:c.hed to VSP within thirty-one (3i)
days of the date such depe:ndent's coverage would have otherwise Icnninated or at ~uch other
rimes as \lSP may request proof. bUI not more frequently than annually.
6.02. noeilmeiltafioI1 of flioibillh': Persom s.:it!siy!ng the requirements for coverage
1 tinder either of the abo ... 'e dass.es shall ~e eligible if:
,, ________________________ ~-I~O-~ ____________________ ~
08/11/94 dd
f?'fVJt4"
•
I
I
I
I
I
)
•
~~.
"';-4-"
,\1'5Ia"i SERVIC'E PLA ... ~
\
(.) in the case of ali Enrollee, the )f'lOividu.l.rs. name af"ld Social Security
N\;mba tw, ber::n reponed hy tht GNUp m VSP in the manner pWI.:id.::rj hereunder, and
(b') I!'! the: c-ase of changes to J <l~r::,ienl's s.(an.:s. the change has been
n:p.l."ted to)' me GrOiJp to VSP in lile manntr pro',ided nerein. A$ indk;a~ed in Paragraph 4,0..
lOOYe, VSP may e:ecl :0 ins~:! the Group's record:i in order to verify elig\biliry of Enrollees
me! Q.epenOent. ?I.in 8ener~,-, ..... dl be a .. 'ai!able only to person'i on ''\''hose behalf premiums have
I:leen paid for t-tu: CU~! period, or Grace Pe:iods oUllined aoove In Par-agraph 4.03. If a
dC!l"ial error LS made, It ..."iJl no< a.ff~.:! ~j-,c coverage w which ~he Covered Person is entitled
under the PLa.1
of thi..5 Pia..'1,
6.fJ.4:. Chanu in £&mill-' Status: In rhe e,'erH of a.n.)' change !n a Co .... ered Person's
f;uni1y sa.rus {by marn.age, Uie addition (e.g., newborn or .adopted child) or delelion of
dependent children, eu;.) 'W'Tinen nou.;e in a fom acceptable to VS? is to be given 10 VSP by
t.~ Cove.m::i Perso."\, or b)' someone e!-;e a.:'ti'l'1g Oil. the Co .... en~d P'!f')Or.· ') behalf. withil'l thin)'-one
become effective Oil the firs: d.ay of ttle month follo .... ing :he requesi (or change, or at such later
Gate as may be requested by or or. betulf oi the Covered Per~n,
Quring d'lc tioirry-one (3J) dJ.y pen0d :lIter birth.
e. _ .. _, ___ ,-, __ "
VI!slO~ SER'\ "ICE PLA."
yn. CQ:'I'TIl\].'HIO:-'-OF COVERlq
7.01. ~: The Consolidaled Omnibus Budge! R~:on.:ili.allon A::[ of 1985
{COBRA) requires that l,mdercemtin circumsta.,.,ces l'1ealth pUr: Oer.etltS J\.;ulablt" to an eLigibie
Ellrollee i1J1d hi!' or ner dependent's be mJde a\'ai;ab:e for pl:rc~.a>e b~' s..1.id perso:1-S: upc.n !he
termination of employment of said Enrollee. or the: trrmini5.tirm of the rtLaltOr.s.hlP be!'oio"ttTl saiJ
EnroUee and 1m or hei dependents. [f. 0i!Kl Ml).' ~o tt'o/C e.'ltent. COBRA applies ~ \.he parties
to this Pian, VSP shall mate the statutOnly~~uired cor,t':'f1...a:!O;'1 co,'c-ragc-,avajlable fer purchase
in ~ ""en COBRA.
I
'-_______________ .I~_.------------~
PLN .;93
( yru. .~RBITRAT!O!'j Of DISPUTES
--------,
a.OL AllY dispule or question arising ~lween VSP and Group or any (cn:em:! Persc-n I
::::::yrn~::~:::ni·n;:::::;ti:tl::;~:::::::c~n::~':~~I~:·: ::!:;~ I
under !he circumstances for ~I~finding and mediation. If a.'1)' IS5~ caMot be resolved in this
fashion~ it shall be subm i(ted to arbi rration.
8.02. The procedure for l.1'bitratlon newJnder .).~all bi: conQucte-d JXlrs.u.ant ~o tile" Rules
of the American Arbitration A.!sociation.
-13-j
'-----------------------------------------PLN -4;'93
... -~--
VISIO~ SERVICE PIA"J
IX. NOTICES
9 .01. Any notices required to be gi \len under th is Plan 10 either Ihe G roup or VSP shall
be in writing and delivered by United States Fjm Class MaiL Notices s.enl to (he Group will
be mailed to the address .shown on the, Group Application. Notices ~,t to VSP shall t>e sent to
dl~ address shown Oil this Plan. NotwithstamHng the abovt. any notices may ~ hand-delivered
by either pany to an appropriate representative of Lhe party, with Ihe burden being on the part
effectin', such Iwld-delivery, to prove, if questioned, that s\..Ich delivery was made.
PLN 4193
.-.
•
~-...--....... --~--.. -----~ ... -.~-".~':":""
\"L..,IO.:'IJ SERVIC~ PLA1""l
x, :>IISCEU,ANEO US
10.01. Entin: P'Ljim: This Plan, the Group Applicatlon, <u~d all Ex.hibits and
attachments. and wy amei".<1ments hereto, CO!\stiw.t(': the entire,um!erst3.pding between th.e parties
znd s.uper-sedeS an)' prior understandings and agreements belw~n !hem, Cllher written or oral.
Any change or amendment to the Plan must be appro¥'ed by an officer of VSP and attached to
be valid. No agent ha:s the authoriry [0 cbarlge this Plan or wa;ve any of its provisions.
10.02. Indemnity: VSP agrees to indemnify, d.efend and. hold harmless Group, irs
s.ha.ref1.oJder.i, directors, offlcers, agents, employees. successors and assigns from and against any
and all t\a.biEty, (\41m, 1,0':.5, ~r\jur:-!, cause of ac~icfl and ~;..pense. (llidlJding defer-:sc costs and
legaJ fee:)) of JJl)' n<1tt.ue w~ • .::.!~oever ;;.ris::ng from the t-ailure or" VSP. as off:cer$, agenlS OJ
emp!oyees, (0 perform -it;,)" 01 (he ac!I',itle:i. dl.;(ies or responsibilities specified herein. Group
agree~ iO ir'tdem:lify, defend .l.o'ld tit;.)1d h<>Imless vsr, its member>. ~hareM.olders, dire\;:lOu,
orf"[C'ers. ageni5.. eml'rJ:-t'es. $u.cces~ors and assigns from and against Ml)' iL'1d aJlliabiiity, Claim,
10'», 'l!1jUf)', "aus.e {If action and e:o.:pense (includmg dt:fens~ COStS and legal fees) of any nafure
w~..i.t:sceYer mSlng Q[ ftsultmg from the failure of Gmu? itS. off~cers m employees to peli'Qrm
i1l1y of the duties ~1r respor.sibilities s~~cified herein.
10.03. J.Ja.Q.ili.u:: Under no circumstances shall VSP or Group be liable fCir the
negligence, wroogful acts or omissions of any doctor, lal>0racory. or ,any other person or
organization pen"orming services or supplying malenals in connection with this Plan.
10.04. Rieht to Reject Claims: VSP reserves [he right 10 reject any and all daims for
servkt:3-or ~eflts whkh a...--e filed WHn 1t more than one h'.mored eighty (180) days after
compktion of services.
10.05. Assi"'nment: Neither thi~ Plan nor any of the ngiJls or ubl:gations of either of
Ute panies hereto may be ~igr.ed or transferred, ex.cepl as may be expressly authorized and
provided herein, withour [he prior written consent of bOth panies hereto.
1 ___ r._m_;u_;_n_i~_:_:_'_O_yt_7_~o_V:_~_~_:_~l_l:_:_~I_"_~_:_O_i:_ld_("_~_I_t:_,_:e_ro_:_~:_'_:"_ff_eo_,:_',_'"_i_,_p_l_an __ b_e_d_'C_i_"_re_d_i'_'_'_ii_d_,_,_"_e/
"--·15·
PLN 4193
--......... ,.... ---.--... -
.; ..
~-~~~ . . " , ..
-.-' ,
10.07. (bOO or l...1~': Willie re-.:ogn!zing thal que'.ttcn(s) and (1ispute(s) hereund.er are
to be-r~:soh-ed by arbitrarion, if f:f(:rt are any n;arfers arising In con.:1ectwo ~'Ith !his Pla.."l which
do become me 5\..bJecl or :eg:aJ pro:::eu, the 1.ppl:cab1e ta .... sJ1ali be (hal of the State of deli\lery
of lhis Man.
W.08.~: AU p~tmQun:s used herem are deemed to refer to ttJe masculine.
fem.inine. neuter. singular. or p\ural, .a..o; the identit;,;l.ies) of &.e pc:rson(s) may r~uLre.
_________ 0
16
0 ---~j
PLN 4/93
• <
=
-----. VL".UO", SERVICE P'I....-\.~ ( -_ ... _--'1
I
EXHIBIT A
VISION SERVICE PLAN
SCHEDULE OF BE. ... 'EFITS
PLAS A
This Schedule lists the vision care services and ;:i:;:ion care mate!":J.ls (0 .... hich CO\'c:rtd PI:'~5
of VISlON SERVICE PLAN CVSP") are entitled. subject to J.'l')-' Copapr.encs 3.."Id other
conditions, limitations it1dJor exclusions stated herein. Vilioo C4.ft' sc:n';,ce:5 and "1Si'XI ca.-e
matmals may be received from any JiC'ef1.sed optometri~. opta.halmnlJ-gisJ. or (:!ISPC;SlnJ
optician. whether Member Docter! or Non-Member Fro,\l~. This ScheduL~ fo!"ms l pan oi
the Plan or Certificate !o which it is attached:.
When Plan Benditl are recci",'ed from .\fe,,",ber Doctor), t.et1efits ::~'X3..nr:~ in Lhc tint c{}iuir.n
belowar: appliC<!ble subje:t to any Capaymerll a!1Q.;Jr !:x-dt.:.cnbl:~· ~:"!!e'<j-b!:::')' ..... W~.e:; ?~2-!l
Benetits are re.ceivc.d irom NOf1-:\{emo.er Pio,,~d~r;. th.' C(1\'cred P~~l:),:' ;-e:rT'~·'.;:sed :0:' s..::h
benefi.ts according to rhe :.chcdu1e i:1 t~e -<?","':".J c,~:'.;rrn b::~o ... :ei" 2r.:.' ,.:.~,;-":':-:::-t't ((::''::' :-r:e;']t
or De.ductiblc. In either even[. COCla\_~':-i;t50 ;:.:;d (': I\:-~'_C::2:::~ 2'-~ ".,',:"I,:? ~"~ r~! .\le.7.ct.·~
Doctor or Non·~1ernber ?ro~!("!.ei :H '[~,:: (i~".! tL~ '.~:-'.','~;:~ ::",':' :<:-'"'.'-:(._~ .;.:--,J ;T:3::::::-. .l:~ ~r~
:>lJpplied,
E..LAr-{ BE~'EF1TS
VISION CARE SERVICES
Vision E;o;:amination Cu\.:red ln Fu.ll
Complete inltiai "'ision .lH;::j~s.i~ u"h'lch ,r:..:kdes an J.prrupr..!I~ C:\2ITlli'.Hi0r1 0: QS'LlaJ
functions. indlJdir.g tnt!: pres:npliC1r1 0r' corre,:-rj\'(: c)e\ol.eJ.r "l1crc :nJi":~led.
Subsequent regular-vision examinarions every 1: :T.ontlis,
l~ __ --C...\.
--_ .. _-
, i
~-... -
-----VIS~ SERVICE PlA~
~JS[Q1:i CARl;; MA I ERIALS MEMlJER DOCIQR
Lenses
Fra."nes
BENEfIT
Single Vision Covered in Full
Bifocal Covered in Fu It
Trifocal Covered in full
Lenticular Co .... ered in Full
Available every 24 months.
Covered in Full
up to Plan Allo ..... 'iiI'.ct:
.~.vailable every 24 monlhs.
LeiiSf'-S and frames inciude SL:('h profe'~s'.I:J~al
include:
I. Prescribing and ordering prover it'n~es:
As.sis:irn~ :r. the selection ot frames;
Verifyin~g the accuracy of fi"isrled 1enses~
Proper tittlng and adju!llmenl of frames',
NQN-~II~ll!ER
BENEFJT
Up to S40.CO
Up '0560.00
Up to S80.00
Ur to SI2S.00
Up to 545.1),)
}.
-I.
5
6.
Subsequenl adju:;.tmell:s 10 frames 1(1 maintain comion and effit.·jcr.c~';
Progress or fOllow-up work as netessary. .
~ ______ ~-_______ J
H
..... ""-"-_ .. ,.---._._-------
CONTACT LENSES
In lieu. of all other Plan Benefits. availabfe nerelmder and when a prescription change is
'W"UTa1lted but in no event more than once in any 24 month period.
Necessary -Contact lenses together wi th necessary pro fessional :.ervices ","'ill be
pf'O"l,'\ded. wiL~ priOt authori:~ation, onlY under one of the follo-mng
ciTCU mscances:
• Followilig catar.aCl surgery
• To correct extreme visual acuity problems. chat ca.ni\OI be CGirected Wlt. ... spectacle
lenses
• Certain COI1ditions of Anisometropia
• Keratoconus
Exam and Materials
Covered iii full
Subject to Cop"~Jm.;-nt/
Deci'JClible ii any
Up to S·W.OO co· .. ·.ard eX2.m
Up to 5210.00 to'Nard c~'nlact
lem esajualiof"l fee, fHt'T1g
CO":l\5 and maienah
ContaCllemes for pr)rpQ5.E~ other than under ,he clrCUffiSI..afiCeS above:
Exam Covered in Full
S Llbje.::t to CopaymenU
Deduclible if anv
MalCrirus A!lowJ.nce-.
Up to S40.00 toward e:tam
Up 10 5105.00 mward contact
len:\ eVJ.lualiDn ree. lining
com an d m a rerial!-
-Materials. aUowance toward contact lens t!vatuation lee. fitting cos.ts. and
mat~rials and equivalent under the VSP program to spectacle lenses and frame.
~fENTIDt:.DUCTIB!,E
The beneii.ts ziescribed herein are ;i.vailabl.e (0. each Covered Person from any participatin5: VSP
Member Doctor at 1'10 cost to the Covered Pe[~on. The Covered Person mu!!1 tollow the proper
procedures by obtaining a VSP benetl! form and presenting if [0. the doctor at !he tlme of the
examination.
A DEDUC"TlBLE AMOUNT OF TWENTY 'pQLLARS.l~;:O.QQJ SHALL BE PAY,\BLE BY
THE COVERED PERSON TO THE />jgIBER DOCTOR AT THE TIME SERVICES ARE
RENDERED.
I
I
VI.. .. ·HO:"oJ SERVICE PLA .. ""
iPW VISION BE~UI
The ~' VtslOf1 benefit is a ... railable 10 CQI;'ered Pers.ons. Wl;O have se'r'ere visual problem.! that
m 1'\0( correct..3ble \!I<l!.." reguLou len~ and is subje<:t to prior approval by VSP consultaflts.
MEMBER DOCTOR
BEXEm
Covered in Full
NON-:'>!EMBER
BENEUr
Compl.eu= low vtsioo anaiy ... ~s and diagnosis which includes a comprehensive eumination
oi Hsual fUlictlons, including I._h~ prescription oj cOrTec[ivC' eye\'iear or vision aids where
InClCi.ted.
75" of Ccst
He maximum Oer"l"efil iisalJabil.': IS Si,(1{YJ.OD tf:>;clwding ..:opaymenl) every two year.s.
Lc"'" V!'Sion bendlis s.~'i.ned from a Non-~,lember provid::r arc subject 10 the SJ.me orne
:irT,Ll$ and cOpl\'1l1enl a.rra.nge,l:ent'i as r~e5cpbed abo .. '\! for i1 Member DOCtor. The Coyered
Person. $houlJ pay ti".e NOl1-: ... l.ember Provl-1er h'ls full fee, Co .... ered PerSCI' will be reimbursed
in. acCDldaJ1ce wilh a.'"I amoum :",O! to e:-;:ceed lIr.'hat VS}' would pay a ,\Iember Doctor in s:milar
c:r;;iJm~1Ces. NOTE: Th~re: is r.o assur...nc.e trJI this amOl.1r1t will be within Ihc 2S %
c-apaymem fearure.
•
l~ ____ --,-"-__ ~j
wheys
•
\,
--'.~-~' -------
~'ISIO~ SERVICE P'L~"
EXCLUSIONS A'ill UMIH TlQ:"S Of BENnm
PATIENT OPTIONS
This Pian is c1eslgned to Clwe:r ... j"l.il n.!¢js. rathc'T tr:lll £Q:.1..mctc m.1letia~,i, \\''her, a Covered
Person selects an~' of r.he fuUowrng ex(ru~ th(' Pizn , .... iil p:J} :"<,J: b25:c eml c.{ tMe allowed lcnses.
and the Covered Penon wjH pay ll'lc ~~tJOO2l com. for t~ opuons
L
2,
3,
4.
5.
6,
7,
g,
9.
10,
il.
12,
BLendt<i I"" ses,
CooQC'! lenst'5 (exa"p( olS :",j(}(eQ ~.sev.~fr' heft'ln.}
Oversize tense:s.
Photochromic Ieo:SC:5; 0 ntol len-Se.$ e.x~ P ~!'1 k ,f i
Progre.ss.ive mw:tJfClC4l le::'l~.
Th~ coating of the lens or !e:'Ises.
The la.--n:nacing of the leta Qr 1,,!I'.s¢s.
A t'raITlC: mal C45I$ m,:'te t..h.a."1 C':e Pi.!.i', .lJ:o ... .:-·,"~
C:;, • .a.in itrnitarlom "r. :0.,;,' ~is'(', .; . .:.re
Cos:r,enc !~~::>,
Or'~:Dn.a1 cosm,:::c rl('c,:)~~
f)V (\.!Jtra·.iole:'1 F~,,:,:~'~:e.:> i, ,l~..::"~
NOT CO\,ERfD
L OnhcptlcS or ;'lsion (.':u:ilrlg :a.~,d ~"~' i'.:).:;;:":I~~(d )c·p?~e,re-nl.'.l lC~!ln?" p:ar:C' k:-,s.:.s {less
than a ± ,.13 dlL)pteT ~ .... ~""er): ('1' , .... 0 ~2:r (,f ;;~:;~j. l:l l:~"J '.If t)]i:"'-":.1I~:
1. Rrolaccmerl1 of l~n~~ J-'":a fr::m-:-~ f'Jr~,~.:.~!;:J ',;;'de{ '.h;s. PiJn "., hi~J, .:!Je IL;st pr bwhn.
e:tcep~ at the DOrm3.t ;ll~~I\~ls \I>~e-n :.en'~ce~ ::'T~ ,;:.t.~r"'l~'<: .2.\':::Jb.bt~,
4. An\" e'w'e e.u.'11inat\on. Of 4.."1'1 corr~ll','(' c',e;"eu rcquLrtJ b:. ;D1 ~mpioyo!'r as a condition
0; employment
vSP MAY, AT ITS DISCRETION, WAIVE A,'lY OF TIlE ?LAN U,!lT,;TIO;-"S IF.lN TIlE
OPlNlON OF VSP'S OPTOMETRIC COSSU!. T.'INTS, IT IS ,'iECES.\,\RY FOR HIE
VlSUAL \VELFP.RE OF THE CovERED PERSON.
L ____________ ~,~· __________ ~j
EXHIBIT B
EXHIBIT B
VlSIO~ SERVICE PL·\... ~
VISION SERVICE PUS
SCHEDULE Of PRDIlUMS
\'ISIO~' SERVICE PI .\:\
SCHEDlTf; OF PRDIID!S
behalf or' each Enro:tee and hls./her Eiigible f)ept:~c.len!;. it Jrw. In rht.' .l.I7'.0'jrr~ j,~<.:.:(;"d ~:::Q';'~
S 3 . .37 per month for ea;::h eligible employee V'I1tMO .... i cepend:!iLts
S1O.00 per month for each e!igibie ~mployee wilh eJigLb!e (ie::rlt"nd~iilS
... .,ronCE:The premium under this Pian is: sLlbjO!Ct 10 ~hange. u:.>On retJ:::'",'aJ, after rile end or lr.e
Initial Plan Term or any subsequent Plan T~rm, or UVJil (na.!'L§:e or' :l:e S~~e-Cl.lle 01 Ber.e:Lt5 oJr
a change in Jfl~ other (crill'S or c{)nditllJ!'1) of (r,;; P::1rL J ------------------------~
•