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City of Palo Alto
City Manager's Report
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HONORABLE CITY COUNCIL
CITY MANAGER DEPARTMENT: HIm .. Resource.
AGENDA DATE: October 3j), 1995 CMR:464:9S
SUBJECT: Am.ad me.t of tbe City of Palo Alto's Conlnd for VISion C ....
Services to aBow for the cODvenia. from s loDy-iDsured V .. ioa Care
Plu Contract to • self-l'IIlIded Visioa Care Plu.
RFPUE5T
This request is 10 ",mend the City's curren! fully-insured .-ision care benefits contract
un&:rwritten by \"1Sion Service Plan(VSP) 10 provide the same senices on a self·funded basis,
RECOMMENDATIONS
Staffrecommends approval of the attached agreement amending the curren! funy insured VISion
Service Plan contract 10 provide for a self· funded contract
i'Oycv IMPYCATIONS
This request does not represent any cb .. oges 10 existing policies,
EXECIJTIVE SL'MMARY
Since 1987, the City of Palo Alto bas provided City employees and theic dependents with vision
care benefits onder an insurance contract undeJwritten by VSP, Existing agreements witl> the
City's wllective bargaining uni1:; provide for maintaining benefits equivalenllo those provided
by YSp( 520.00 deductible, Plan A), with moolh]y premiums paid by the City.
The contract ",,,!h YSP is an "experi.n<:e·rated" insurance COIlt.-act for which 1110 City pays
premiums based 00 the IoIal cost of an paid claims and reserves phIS the insurers costs and
profits. Since 1981,premiums have increased ata rate c.fapproximately 4%pcr year, This
year, YSP is re<[UeSting an increase of 6, I Yo. The p<O\Xl'Od increase will require an annual
premium of $96,085,00, Poid claims are projected 10 be approximately 577,OOO.O(l-
CMR.:464:9S Page J of J
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Over the years, as part of the premium, VSP has held reserves for incurred but Do!
reported(IBNR) claims. VSP does DO( credit the City with any interest earned on !he reserves
held. This year, the reserve will be increased \0 19%($18,256) of annual premiU'I1, an m..-rease
ofS4,667 over the last year.
Out of coocem over the rate and Ii:equency of premium ~ staff evaluated plans offered
by 0Iher insurers, including opOOaI chains. These plans were unable 10 offer a comparable panel
ofproviders. VSP's panel ofproviders is nearly twice as large as those offered by othet" insured
plans.
Staff also evaluated aJl alternative funding arrangement to the current "experien<:e-rated"
method, • self insurance or self-funded approach. Under this arrangemen~ the City would pay
VSP b all claims in additioo 10 • fee(percentage of paid claims) fu< administrative services.
There would be no change in the level of benefits or administration. The same panel of
providen, the same claims and Ibe same administrative sonices would be provided !>} VSP.
A self-funded cootract would produce annual cash flow savings ofapproxirnately 57,000.00 as
sho",n below.
INSURED SELF-INSURED
Paid Claims $17,000. 577,000.
Admlnistrationfpr<>lit 514,418. $11.550
Rosen'CS Adjustmen; $ 4,667.
Total CcstJPremium $96,085 $88,550
Savings $ 7,535
The only disadvantage to the City of Palo Aho would be in the area of risk a."umplioo in the
even! paid claims exceed projected claims costs. However, the chance of any adverse exposure
is minirnaI due 10 benefit funitIDoos and the oon-<:ata;1rophic nature of tile vision plan risk. The
City's claims and administrative costs have never exceeded "SP's p<ojectioos.
In addition,. self-funded arra.'gement would also allow the City 10 include the administration
oCtbe employee Safety Glasses program \0 VSP', contract at • reasonable cost. The self-funded
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"""tract would add needed oost COOlrols, reduce internal administration and utJ1v"" VSP 's panel
of providers.
FISCAL IMPACf
There is a projected savings ofS7,535 resulting from this recommendation. Fund'mg fur vision
care expenditures has been provided in the 1995-96 budget.
ENYJRONMENIAI. ASSf',SSMfNT
This is 001 • project fur !he purposes oi the California Environmental Quality A,ot,
ATIACHMEN}'S
L VSP Plan Documenl
PREPARED BY, Uonard Zucker, Mana,g" cr<>fEmployee Benefits
DEPARTMENTHEADR£VIEW: ~,/L, (" /L __ ~ JA'~R ~~=-----
CITY MANAGER APPROVAL:
-----,,~~ SERVlCEP~~
Group Name
Group Number
SIlUe oi DeIivuy
VlSION SERVICE PLAN
3333 Qua/ity Drive
Raocbo CC<1Io •• , c.Ji{ornia 95670
GROOP VISION CARE PLAN
ADMINlSTRATIVE SERVICES PROGRAM
cmOFPAWALTO
00102584
CALIFORNIA
Amounts Due Dale FIRST DAY OF MONTH Plan Tenn
OCTOBER 1, 1995
TWELU: (U)
MONTHS
10 coosiderntion of the statements and agreements CODtained in the Group Application and
in coosiderntion oi payment by the Group of the amounts due as berein provided, VISION
SERVICE PLAN ("VSP") ag=s k> pnw;de certain indi,iduals under Ibis Group VISion Care
Plan ("Plan J the benefits provided berein, subject 10 the excepOoos, limftatiom and exolusloos
hereinafter set fo<th. This Plan is delivered in and governed by the laws of the = oi delivery
and is subject 10 the Ier!Ds and conditions recited on the subsequent pages bereof, ",bid, are •
part oi Ibis Plan.
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VSP~VCP-ASP-I2192
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I.
n.
m.
IV.
V.
VI.
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IX.
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VISION SERVICE PLAN
GROUP VISION CARE PLAN
ADMINISTRATIVE SERVICES PROORAM
TABLE OF CONTENTS
llll.E
DERNITIONS
TERM, TERMINATION, AND RENEWAL
OBUGATIONS OF VSP
OBUGA1lONS OF TIrE GROUP
OBUGA TIONS OF COVERED PERSONS UNDER TIrE P1Al',
EUGIBIUTY FOR COVERAGE
CONTINUATION OF COVERAGE
ARBITRATION OF OOPtlTES
NOTICES
MISCEl.U.NEOUS
ATTACHMENTS
EXHIBIT A -SCHEDULE OF BENEfITS
EXHIBIT B· SCHEDULE OF ADVANCE PAYMENT A.1ID
ADMINISTRATIVE FEE
AD[)ENDUM
ADDlTlONAL BENEFIT -SAFETY EYEWEAR
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rAGE
1
4
S
1
9
10
12
13
14
15
SPUJ 4193
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VISION SERnCE PLAN
GR()(JP VISION CARE PiAN
L PEFINITlOM
Key terms u.sed ill !his Plan are defined and sball bave the meaning set krth as fonD," s,
urue.. the context c( • term's ..." .. clearly requires otherwise.
1.01 AIlMINJSTIlATIVE FEE: The p;!ymenu made 10 VSP by 0< on bebalf of
Group in coosideration. of administrative services rendered.
1.02. ADMINlSTRArn"E~ERY1CESPROGR.,,"Y;: A grou;>vision care plan wbere
by Group pays VSP for the Plan Benefits in addition 10 a monthly Administrative Fee.
1.03. AP'ik"iCE PAY>WIT: The amount paid in advance 10 VSP by or on bebalf
of Group 10 cover the _:uN bet;efit costs of Group for on. (1) month.
1.Q4_ A."!ISQMETROPJA:.1\' condition of unequal refractive Stale for the two eyes.,
one eye requiring • different lens correction than the otkr.
LOS. BENEFIT FOR.'"' A form ",sued by YSP identifying the inc!hidual named
thereon as • Covered Penon of VSP. and idelltifying those Plan Bener'" 10 wlri<:h Covered
Pmon is entitled.
1.Q6. CONFIDENI'IAL !\-lATTER: All coofidentiAI oc personal wO<m.tion
. ooocernfng EIle medical, personal, financial or busi...., affairs of Covered Persons acquired in
the coors< of provhling Plan BeDeUts bereunder.
I.W. COPAXMDiTS: AJJy amouDts ""luired 10 be paid by or on behalf of •
Covered Penon for Plan Benefits ,.bitk are not fuDy covered.
1.08. coyERED PERSON: Ad Enrollee 0< Eligible Dependent "ho meets VSP's
eligibility criteria and "bo is covered under this Plan.
1.09. DED!,'CIllII.J:: A., amount .. '!lie. is paid by 0< on bebalf DC • Co,-ered Person
IOward Plan Benefits. It applies separate!y 10 the Plan Benefits incurred by each Covered
Pe=-Plan Benefits will be paid for only those expenses, services, 0< materials whick are
more than the dcducOOle amount
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------~I<:N SERVICE PCXN ------
1.10. WGIBI,I; DIJ'E1o!DENT: AIly legal dependent of an Enrollee of Grou~ wbe
meeIS !he criteria lOr eligibility e.ta!>ll,hed by Group and approved by VSP in ArtkJe Vl of <his
PI&a ooder which such E.oroIIee is covered.
1.11. IMJ;;RGENCY CONDITION: A coodition ,.,1ll<:h 'requires the Covered Pmon
oc Eligible Dependents to "",I< immediate yjs;on care either from • YSP Member DocIor or
Noll· VSP Member Provider.
1.12. 'ENROll Q: All empwyee or member of Group ,,110 meets !:he criteria foe'
eligibility specified under YI. El.lGll!lllTi FOR CQVElAGE.
1.1). GllOL'P: An employer or otbf" e!ltity .,1ll<:1l cootr>cts ... i<h YSP lOr coverage
under this PIon in order 10 provlde 'ri-.;oo care coverage 10 its Enroll ... and !heir Eligible
Depeodeots.
1.14. GRoup APPI.lCATION: TM foon <igru:d by an authorized representative of
the GIOOp !<J signify tbe Gcoop", intention to have its Enrollees and their Eligible Depeodents
be<:omc CO'iered Persacs of VSP"
US. GRoup YJSION CARt PYI'I! (.1:;0. 'THE PI.AN"): The Plan p~ by
VSP in favo< of a Groul'. under which its Enron ... oc members, and their Eligible Depeodeots
are entitled 10 become CoveIed Persons of VSP and receive Plan Benef'.ts in accordance with
!he terms of seell Plan.
U6. XERA TOCQ1\TS: A developmeoral or dystrophic defomUry of the Com'" in
,.,hich it becomes roneshaped due 10 • thinning and ""'!Ching of the ~,"e in its centraI area.
1.11. MEMBER DOCTOR: AIl optometrist 0< ophthalmologist licensed and
otherwise qualified 10 practice vision care andIoc provide vision C3IO lIL1lerials ,.,ho bas
roOlIac'.ed wi<II VSP 10 provide vision care se~s andice vision care materials on bebalf of
Cov.:ell Persons of VSP.
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vlibo..~ SERVICE Pr~~ ---__..
1.18. NON-MEMBER PROVIDER, AIJ~ optometri&, optictan, oph!baJmo~ .... or
other 1icenscd and qualified vlsio!I care provider wllo ha.< not contracted "illl vSP 10 provide
vision care seMce$ and/or vision care materials 10 Covered Penoos of vsp.
1.19. PLAN APMINlSTBATOR: The person specifically '" designated on the
appllcation. or if "" administrator is no< SO designated, the Group.
1.20. PLAN BmEFITS, The vision care services and vision care malerials .,'bleh
• 1:ovcrell PetSOn is eo6tled 10 "",eive by virtue 0{ to'enge under this Plan, as defined in the
Scbedol. 0{ Benefiu >ttItbW bemo u El<!u'bit "-
1,21. RENEWAL DATE: The dale on wblek \be Plan shal1 rene'll, ""expire ifproper
nodce a given.
1.22. sgpmB.E OF l!F.!!iYJ1£: The document, attached bere10 as Exlu'bir A,
whicillists the vision care services and. vision care materials "hieD. a Covered Persoc is entitled
10 receive by virtue of this Plan.
1.23. SlJ!IDflLE OFAPVA1'lCE fAl'MEl'!"'I A.W ADMll'ooJSTRAID'E FEY.: The
dot=cl, anacbed beretO as Ex.'u'b;' B. which stales rile paymect; 10 be made'" YSP by 0< on
bebalf of • Coverell Penon 10 ootitle himlber 10 Plan Becefils.
1.24. VISUALLY NECfAAAAY OR APPROPRIATE: Seroices illld materials
medically or visually necessary 10 ..... ore or maintain • patio"" s visual acuity il!ld healtll and Co<
which Ibere is no Iess expensive profe$sionally accep!able alternative.
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n. TERM. TQM!NAlJON. A.>m JlENiWAL
2.1l \. 1'bi> Plan .ball become effecU'e on the date fin< .Ix" ... .ate<!. &:>1 .tIaIl remain
in effect for the Plan Term. At. the expiradou 01 the Plan Term, it shall "'-o •• month to
month bam unles.s either puty 00tifics the otiIer in .,riling, at \eaSt "''<1)' (60) da~. Wo .. the
end of the Plan Term tlIat suck puty ;, unwilliJlg 10 reDeW the Plan. If sue. ootic:. is give., the
Plan sIlaIl ~ at 12:00 midnight on the last day of the Plan Tern> unless the poni .. reocll
mutual agreement on its renewal.
2.02, In the event of termination of this Plan by either party. Groop agrees \0 prov'.de
fimds for paymeut purnwtt 10 benefiI forms issued prior 10 the termination dole, provided suck
benefit forms = !\led .. ith VSP "illlia .!lx (6) meath. after term1na!loD 01 this P'"","
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-----V~ION SERVICE PLru'"
m. QBUQA110NS OF vsP
),01. ee .. nge of C&!ered Persons: vSP w.J! er.ro1l foe coverage eack eligible
Enrollee, and hWber Eligible Dependents. if dependent coverage is provided, all 0( "'!>om shall
be referred 10 upOII their enroll1'lent as 'Covered Persoos.· To instilllte coverage, Group may
be required by VSP 10 complete and sign • Group Application and forward "'co app1icarioo 10
VSP, along with infonnation reguding Enrollees and Eligible Dependents, and all applicable
amoonts due. ~fer 10 VI. ELlGlBilITY FOR COVERAGE foe furohcr detaih.)
FclIowing the enroOment 0( the Covered Persons, VSP will make available 10 all
Covered Penons • V"lSicn Care Brocbu.... Sues BlOCh"", will S!!mmarize the Ienns and
conditio"" set forth in this PIaIl.
3.02. ProrisioD of PI.,. &neC"J!s: Through its Member Doctors (0< Illrougb otber
licensed vision can: provide" in = wbore • Covered Penon c!loose< 10 receive Plao Benefits
from a Noo-Member Provkler) VSP sball provide Covered *""" .. >tiCk Plan BenefllS listed in
the Schedule 0( BenefiIs, Exhibit A bereto, as may be \rJSUalIy Necessary or App~e,
SUbject to any limitations, exclusions, c!educnoles, 0< copaymeots therein stated. Wbea.
Covered Person desires 10 receive P1ao BenefItS, the Covered Person shall CDDtact VSP. VSP
shall fol"ward a Benefit Form 10 the eligible Covered Person, tot: use iII re.:eMng Plan Benefits
from • Member Doctor, or tot: reimbursement wbeD Plan Benefits are received from • N0n
Member Provider. Beoefit Form. shall be issued 10 Covered Persons by VSP in accordance
with the Jatest eligibility information furnisbed by Group. Any Benefil Form so issued by VSP
shall CW>rirute • certification 10 the VSP Member Doctor tbat paymeD! will be made, and VSP
.ba11 DOl be bold liable 10 Group for any Benefit Form. issued in error, provided they were
issued in accordance with these provisioos. Covered Persoos are required 10 obtaia the BeIletil
Form prior 10 .... 'dng P1ao Beoefits only in cases in ,·l!iclo :'oe C""",red P:non intends 10 seek
P1ao Benefits from a Member DoclO< (See Sectioo 5.03 foe further details). VSP ,haD process
requests foe Benefit Forms 'IIhlcb ,ban be fol"warded 10 VSP by Covered Person" Group, or by
the P .... n AdministIator. VSP shall reimburse Member Doctors foe P1ao Benefiu provkled '"
SPlN 4193
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1 __ ---~Io."j SERVICE ~~
C~ Persoo<, or reimburse Covered Pencns li>r PLalI Beoe/i13 received fm.n Noo-Mmlber
Provider>, less any app6cabl. ded;Jctible or copayment, within • reasollib!e time but DOC """"
I !ban:<>rty-fivc (45) <lay, alier VSP bas =ived the <omplere<! Benefic ""tID fn>tn ei!!Jer its
•
, Member Doctor or Cu;ered Pe.-son. VSP shall furnish 10 Group oa • lDOIl<bly basis •• Ii.<! 0(
all benefits paid pursuant 10 lltis Pl.a!I.
3.03. PelmpinatNg of VJsuaJ Nes;esrity: P1an Benefits are CO\Iered' only whea and
10 the extent. thai lI1ey are deemed V....uy N=sary or Apptq>riale Ii>r the proper tttatment
0(. Covered Person', cooditioa Question. involving ne<:essity or appropriateness of tt<atmem
shall be decided by the Member Docror (or Non-l.rembet Provi<!erj =p<lIlSlOJe Ii>r tlJe CovClCd
Pet>OQ', care and are subje.:t 10 review by YSP. Any objection. of a Covered PeI>On relaclng
10 Stlcl! decisions may be made 10 VSP at the address give. herein.
3.04. Prvflsion 01 Inrormation to Covered Persons: VSP shall make avai!abIe 10 the
Covered Persoas oecessary infonnatioo describing Plan BenefItS and rile appropriate .,erllod for
!ISing them. A copy 0( Ihis PJan shall be pl3<;ed wkh Group and also .,;]I be made .valIab!e at
the offices 01 VSP Ii>r any Covered Persons ,,'00 wish 10 inspect or copy it. VSP shall prooide
10 Covered Persons an updated list of Ill. Member Docton' names, addresses •• lId telephone
numben.
3.05. Pre!en.tiop of Confideotjaflty: VSP shall hold in strict COIlfidence all
confideDtial matters and .,.<!Cis< its best efforts 10 prevent any 0( its employees, Member
Docton, « agents, from cfuclosing any confidential marler, «copt 10 the e;deo' !bat such
disclosure is necessar)J 10 enable any of the ahove 10 per!OOn their oIJIlgaOODS UDder this PLalI,
in<:.1uc5Dg but not limited 10 sharing inf«maOoD with medical information !nt=us, or as may
o<berwise be required by law.
3.06_ Emer:;eJlC1' " .... !Sian Cal"!!: In emergency cases, when vision ~ is necessary.
Covered Persons may 00tafu Plan BenefllS by contacting. Member [)o.;1or or Non-Member
Provider. lleimbursemeDl is subject Ie l1le same provi5ioD' as stated elsewbere betein.
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IV. OBUGATIQNS OF GROLl'
4.01. Ideotilic:atiop of Eligible Eprol!ee!; An EnroDee is eligible for "",'erage under
this Plan, if hefsbe 52tisfies the enro1Iment crireria specified in Par.>gnph 6.01(0) and/or as
munWly agreed to by VSP and Grou? By the effective date of this P'.an, Group ,hall provide
VSP willi • listing, in a form approved by VSP of all of its Enrollees ",bo are eligible for
coverage UDder this Plan .. d !hat dale and a designation d famt."'y stalUS for cae • .ruck
Enrollee, if depeDdent coverage is provided. Thereafter, Group sball supply to VSP on or
before the last day d each month, in • fonn approved by VSP 0 );sting 0( all En.."lIees, ... itO
• deai8na rion of family status, 10 be added 10 0< deleted from VSP'. cov'Jag< ro,'1l:rs foe the
su<:ceeding 1OOIlth.
4.02. Benef"Jt Cnss and Adv!iilrK1' Payment: Group shall provide an fuods necessary
K' pay the coyered costs 0( professional serv1ces and ophtbalmk marerlals (Plan. Benefits)
furnished to Covered Persocs pursuant to this Plan. In Qrder 10 assure timely and adequate
payment, Group agrees 10 make an Advance Payment as outlined on the atucbed Scbedule c,f
Advance Paymellt and Administraove Fee. Exhibit B. 'Ibis Advance Payment is an estimate of
benefit co.u for nne (1) month. Group agrees 10 pay the actual CO&> 0( bene!' ... on a moothly
basis .. ~.Ihln lea (10) days after receipt of VSP's statement d benefits paid. The Advance
Payment amount may be adjusted eack Plan 1erm if the av""'ge of monthly benefit costs
increases {)I' decreases. 'The panies agree that. such Advance n.:;nnent is reimbursable 10 the
Group Ilp01l rennlnarioD d this Plan, after the Group's iOOel>tedness 10 VSP andlor its beccf,.
prov;ders bas been satisfied. Rewover, lIJOOUnts paid to VSP as Advance Payment !.hall not be
considered ~ d lhe Group. and need not be held in tnist by Vsp.
4.Q3. Admjnistrative F..,: Additionally, on 0< before the first day of each lllOOtll.
Group shall remit 10 YSp an Administrative Fee as outlined 011 the attacbed Schedule of Advance
Paymem and Admlnistratlve Fee, Exhibit B,
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----~IO'~ SEJtVICE iiiA.~ -----....
YSP may tbange the Administr.Wve Fee sIlO"''' oa the attached Schedule of AdvalICC
P>yment llld Administtative Fee, Exhibi.! B, by ,iviDg 11>. GrollI' at least si'<ty (60) !Ia)'l advaDce
-Wlt01I DOtice. Clla!>ge wiiI DOt be made more: often than 0""0 during any !Welve Cl2) mootll
perlOO nnle .. there is • cbang< in the Schedule of Benefits or • change in >1ly other lema 0I:d
conditions of the Plan.
Notwltbstanding the above, VSP 1eSCN" the right 10 increase amounts due bero.mc!er
by the amount of any fox or l3SeSSlIIenl DOt now in effect which is subsequently levied b) any
m:On: authority, .,bk:1I iJ attr;oow.le to the amounts due VSF from Group.
4_04. Grac:e Period; (hoop !hall be 2iIowed. grace period of thirty-<>DC (31) day.
follow'"" !he doe dale for makiog any paymeut of amounts due under tlris Pla". DIlriDg said
gnu period, tlris Plan sllaII reaWn in fun fore<: and effect for an Covered PersoIlS covered
bereunder.
IfGroop fails to make any l"-ymenl of amounts due by the end of any grace period, VSP
may notify Group lhallhe payment of amounts due bas not beea made, lhal coverage is canceled
and lhallhe Group is responsible for l"-yment for an Plan Benefits provided to Covered Persoos
after the las< period for which amOOIllS due were funy paid, including the grace perlOO.
4.05_ Other Information to AA Proyjded: Group shall furniM> to VSP monthly during
the effe<tive period of Ibis Plan 5OC~ information as may =soru!bly be JeqUired by VSP for the
purposes of tlris Plan, including llsting. of """Ol Enrollees, I<rmiruuicDS of eligibility, .ad
cbang .. in the family swus of covered Enrollee.. Socb information shall be supplied in • form
spe<ified by VSP. 111 addition, Group sball, ",ben requested, make .vallab .. for inspection b~
VSP such =ords as may bave bearing on the coverage of Covered Persoos uoder lh.is Plan.
4.1)6. Dlstrjbutiog pf Requind DogJments: Group.gtee' to distribute 10 &ro\loeS,
any di5cJosure I'ornts, ptt.n summaries or odler mareriaJ tl13l may be required 10 be given to pl2n
subscriben by any regulatory autllorily_ Snell materials shall be distributed by GrOIlp 10
Enro!l<es DO IaIer than thirty (.lO) days after the receipt thereof.
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____ ---V~~ SERVICE PLCN ------
V. OBUCA11ONS OF COVDnID PERSONS COYERtm tJ:I!I)ER THE !'LAo"
5.01 ~: By this Plan, Group makes ccyerage available 10 its Enroll= .'ld
tb* Eligible Dependents, if c!ep<ndeut """........ is provided. However,!his Plan may be
amended 0< _00 by agreem<IlI bel,.,... VSP and Group ... ithout the COQSe.' 0<
COOCurre:lCe of !he Cov"",,, Persoas. 'Ibis Plan, and all Exhibit:; and alI.attachments and any
amendment! berelO, shaJl consti""e VSP'> sole and entire tmdertakillg !O Covered Pc""""
covered under this Plan.
All persons COY"",,, os Covered Pc""". under this Plan shall have the fulIo"ing
obligations os , coo.fuion of their coyelllge:
5.02. Deductible! aDd C.payments r ... Seryice; Received: Wlle.-e," indicated 0"
the Schedule of &oefiu, Exhibit A bereIo, deductibles and/or copaymen!S are required fo<
certain Plan Benefits, these deductible. aodIor copayments sbaII be the persooal responsibilily
of the Covered Person receiving the care and ",,,,,-be paid 10 the vision care provider ("'bether
3 Member DocIo£ or Noo-Member Provider) on ,be date the services are rendered.
5.03. Approval 01 Seryjqs: A C<Wered Pe""" must receive approval before visiting
a Member Docto£. Socii approval is received by obtaining from YSP • &nefif: Form. Sbeald
the Cov"",,, Person receive Plan Becefl!5 from • Member Docto£ wl!llout socII approval, <ben
fo< the ~ of those Plan Benefits provjded 10 the Covered Person, !he provider will be
COllsidered • Non-Member Provider, and the benefits available will be limi,ed 10 !bose fo< a
Non-Member Provider.
5.04_ Complaints and GrieVinG.,.; Tune or Action: Covered Persons shaJl repot! allY
complaints and/or grievances '" VSP at the address giveo herein. No actio. in Ia ... or in equity
sbalI be brougb! 10 recover on the Plan prio< 10 !he expiration of sixty (60) day. after the BenefIt
Fe<m and any appilcab1e invoices have been filed "'ith YSP_ No such !Ct."" shall be brou,ght
after the expiration of three (3) years from the last date that the &nefll FOOD and any applicable
invoices may be submit!ed 10 YSP, in accordance with the ICrms of l'lls Plan.
-9-
PLN 4193
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-----€lsION' SERVICE klc-\1"""
VI. P .ffiIBU.ITY FOIl COVERAGE
6.()1. Eljrjhj!j!y Criteria: Individuals ,.·ill be a<:<:epted f<>< roIIet>ge ~"nder only
upon meeting an the applicable nquirements set forth below.
{a) Eunll!ees: To be eligible for coverage, • perwn m'''st:
(1) currently be an emp!o)lee or member 0( the Group, and
(2) med the criteria ~ in tlIe coverage criteria mut\lally agreed
upon by Group and VSP.
(b) fJlt!h1e Depeodenp;: If dependent <:overage is p=-ided, the perso!lS
eligible fur ""verage as dependents shall include:
(1) the \eg>l spouse of any En..",nee, and
(2) an, nnmarriod child 0( an Enrollee, kl<.luding any natun1 child from
the moment of birth, legally adopted child from the moment of pla<:emeo, in the residence 0( the
Employ"", 0< o<her child for wbam • coort 11oId< the Enrollee ~Ie; and
(A) for wbose support the Enrollee is legally responsible and '01110
I!as not yet attained the age of nineteea (19) years, 0<
(8) who is chiefly dependeD! upon the Enro!le<: for suppon. b>S
not yet attained !he age of twenty-six (26) yean;, and is currelltly enrolled as • full-time studen,
in goed standing actlvely pIlTSDing • degree 0< certificate at • recognized edocotional institution.
(3) as further defined by Group_
If I dependent, D!lDlaIried child prioc to attainment of the prescribed age for rerminauoo
of efigibility becomes, and continues 10 be, incapable of self .... stainiog employment ba:aU1< '"
mental 0< physical disability, that Eligible D..'P""deoCs co ... erage sball 00( terminale so 1001 iL>
be remains • dependent and the Enrollee's covorage remains in force; PROVIDED !liar
satisf~ proo( of the dependent', incapaci<J can be furnished 10 VSP within thirty-<me (3"
days of the date sock dependent', coverage would have otherwise terminated oc at such other
limes IS VSi' may request proof, but 00( more frequently than annually.
6.02. Docwn!!!!latjoD of Eliglbiljty: Persons satisfying the requirements for coverage
UDder either of the above classes sIta1l be eligible if:
-10-
091QS195 ye
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~j~~~~£2:~·:'~:1<r~;'~;~:~-!"-::~~. _' __ '_,~~.oc
----V&ON'SERVICE PL(t",
(a) in Ille case 0( an Enrollee, Ille indivrouaJ' S !llI1Ile and Social Security
Number bas been reported by Ille Groop 10 YSP in lIle l!l3)U1er provided be=oder, and
(b) in Ille cue 0( cbanges 10 • depecdent', SWUs, Ille cbange has been
reported by Ille Groop It> VSP in Ille manner provided bereiIL A! in<!k3ted in P".r..grapb 4.05
above, YSP may elect 10 irupect Ille Groop's records in Older 10 verify e6gi!lilily 0( Earo!Joes
aDd dependect.!. PIac Benefits ..;II be avanable only 10 penons on ",bose bebalf a!!lOOll!3 due
bave been paid for the cu=nt period, oc Gmce Periods outlined above in Paragrapb 4,04_ If
• clerical error is maa, it ...m not affe.."1 Ille coverage 10 ,.!rich Ille Covered Penoc is ectitled
uoder !he Plan.
6.03 Change of Particioa&D Requirements, CODtriln/tjon oC F ..... acd EU"ibilitv
&k:;: Composition of the GrQup, pen:eotage 0( Enro!lees covered noder the Plan, aDd
e6gjbili<y r<quiremeOt.!, are material 10 YSP', ob6gations coder this Plan. During Ille term 0(
this Plan, Group may not change its composition, pen:eDtage of Enrollees covered, oc eligibility
requiremeDts, in any w.y "Ilk. affects YSP', obligations bereunder .eloss YSP consent.! I<l such
change in writing. YSP may roquire !he Group 10 make written ""!uest for any such change at
Ie.st sixty (60) day. prioc 10 <be proposed effective date 0( <be cbange. Nothing berein sball
Iimlt Group's ability 10 add Enrollees and' oc EligJble Dependents in accordaoce witb me terms
0( this Plan.
6.04. Ch?nge in family Status: In the event of any change i"l a Covered Penoo·s
family ,1lllUs {by marn.".., !he addition (e.g., ne .. 'OOm or adopcro child) or deletion 0(
dependecl childrea, etc.) written notice in • form acceptable 10 YSP is 10 be given 10 VSP bJ
!he Covered Petson, oc bJ someone else acring 00 <be Co~ered Por<on's bebalf, within thirty-<ln.
(31) daY' of suell change. lfsuch ootice is given, Ille change in !he Covered Pe"".', status "ill
become effective on the firsl day of the: month fonowmg the request foc change, or at such bter
date as may be '"'}Ues!ed by ()< on bebalf 0( the Covered Person. A oe",bons ..-ill be covered
during the thirty-ooe (31) day period after binlL
-11-
SPLN 4193
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____ ~--~ION SERVICE &~'"
va. CO/lo'TINVATJON OF COVERAGE:
1.{)1. COBRA: Th= Coosolidaled Omnibus &dget R:coociliation A...""t of 1985
(COBRA) require< !hat under =in cir<:umstaDCeS ~ealth plan benefits ,v,;lab!. 10 an .ng"l>le
Enrollee and his or !>cr dependeots be made available for pu.'1:base by said PO""""' upon the
termlnatictl 0{ employment cl said Enroilec, or the rermiDation 0( the relatiooshlp between said
E.nroIIce and iii, C( her dependents. If, and on!y 10 the extent, COBRA oppIles 10 the parties
to this Plan, VSP sIlaIJ make the statutorily-~"ired cootinoatioo coverage available for ptrn:base
ill accmdance with COBRA.
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----~IONSERVICE~ ----_
ym. W!TBADON Qf DISP'lllTS:
8.01. .1."1 ~ Il< 'l,Ilestio<I arisillg lletWee. VSP and Groop «"')1 Cove,ed Ptno.
iJlvoMng die appl\catioo, ~, or ~ uoder this PIa" s!lalJ be settled. if
poMible by iUJUcabr. ar><l informal .. godadoas, alle-wlng $<lell opportunity as may be appropda1e
under die cimunsta1JCe< foe fact-finding and me<!iatio<L If any issue C3M()( be resclvod in thls
!ashlon, it shall be !lll>miru:d 10 axbitl1ltiorL
8.02. Tbe:pr<:a<lu~ foe atbitAti<ou bcreu!!der s!lalJ be cO<><lucted p= 10 Ill. Rules
0( !he Americu ArlliuaDoa Associatioll..
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l'LN 4;'93
~I(NSERVICE~
lX. NOTICES
9.01. Any notices ~uind 10 be given .nder this Plan lOei!her the G""'P"" VSP shall
be in ",riling and deliv~ by Uni"'" Statu F'mt Class Mail. Notice< seDt 10 the Group will
be malled to the address sbe," 00 the Groop Application. Notice< sent 10 VSP shall be sentI<>
the address sI>ow1I on this Plan. Notw~g the abo_e, any notices may be hand-d<:livere<l
by either potty to 111 approprialc represeotative 0( the palty, with the burde11 being en llIe part
el'fecting sod band-de!ivery, 10 prove, if queslic1led, thai suck delivery "' ... made.
-14-
P1.N 4193
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x. MlSCEJJM"EOUS
10.01. Entjrt Plan: This Plan, the Group Ap:l1katic.., and all Exhihito ODe!
attIChm.-o~, and any amendmeuu l>ere"" consti!UllO!be enti!~ under.;tan<fmg between tile parties
and ~ any prior ~gs and agreement. between Il>em, eitber .. nn.ea ot onJ.
Any ~bange or amendmem 10 !he Plan must be awroved by an officl:r of VSP and attacil«l1O
be valid. No agent has the authority 10 cbange this Plan or "'aive any of ito provisions.
10.02. Jm!.mpjty; VSP agrees 10 indemnify, defend and bold barmless Group, its
shareholder.;. di=to<s, Officefs, agoins, employees, succe<SQrS and assign. from and against any
and alllia!>illty, claJm, loss, injury, cause of action and expense (mcluding def= costs and
legal fees) of an, nanlIe "batsoever arising from the failure of YSP, its offio:", agents 0<
employees. 10 pezform any of the activities, dune. or responsibilities specified herein. Group
..,... 10 indemnify, defend and bold twmIess YSP, its members, sbarebokfers, directors,
officl:rs, agents, employees, StKce5SO<> and ""signs from and against any and all liability, claJm,
10M, injury, canse of >cOOn and expense (lllCluding defense costs and legal fees) of any nature
... bWoever arlsin( or resuIting from the failure of Group, its officers 0< employees 10 perfonn
any of the duI:ies or =JlOllSibilities specified herein.
10.ro. U.I!i!ity: Under no ciIwmstances sl!an VSP or Group be llal>le for the
negligence, wrongful acts or omissions of any doclo<, tal>oratory, or any odIer pe""" or
organitation perfo<miDg services or supplying materials in coonecion wim this Plan.
10.<l4. RiPt \0 R@jectClaims: VSP ",,,,!".os the right 10 reject any and all claims for
services oc benefits .,rueh are filed .,itlI iI: more than one hundred eighty (180) days after
ccmpletion of services.
10.05. Amrnm.l!t: Neither this Plan "'" any of the rights O£ obligatio[l5 of either of
the parties bereto may be assigned 0< transferred, except as rna y be exp<e'isly authorized and
provided herein. without the prior written consent of bo<h parties berero.
10.06. Seymbillty: Slloold any provision of this Plan be declared invalid, the
remaining provisions sbaJl >email! in fun force and cff<lCt.
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v6ONSERVICE~ ----
10-07. C!J'*" ot Law, WbiJe recognizing that question(s) and dispute(s) bereuneer Ole
10 be reooIved by aroination, if !here ... any matters af.;mg in coonection "illt this Plan which
do become t!Ie subject of legal process, t!Ie applicable law sllall be that of 1M State of delivery
of !hi> Plan.
10.08.~, All proOOlIDS used berein ... deemed 10 refer 10 t!Ie m&.IC\1Iine,
femIDiDe, neuter, slngular, or plural, as 1M idcntity(lCS) of the persoo{s) may require.
-16-
PLN 4i9l
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~SERVICEPLttR ---.......
EXlDBlT A
GENERAL
VlSION SERVICE PLAN
SCHIDULE OF BENEFITS
PLANA
This Schedule lists die v'..,;on ""'" suvices and visioo care materiaJs 10 "hic~ Covered Persons
of VISION SERVICE PLAN ("VSP") :ore entitled. subject 10 any Copayment! and od>et
conditioos, Iimita!ioos udlor exclusioos stated herein. VlSion care sel"V1CeS and vi.sioo care
materials may be received from any li<:ensed vptomemst, opbthalmologist. or dispensing
optician, ",l:ethet Membec DocIon O£ Non-Member Prov;den. This Scbedulc bms • part 01
die Plan or ~ 10 "hick it is attached.
WIleD J'I.an Benefits are received from Member Doctors. benefits appearing in !be first cohlmn
below are applicable subjoc:110 any Copayment andfor Ded!lCtilJIe as stated below. WI!ea Plan
BeDetit! are received from Non-Member Provide". die Covered Person is re.imbur>ed for suck
benefits according 10 !he scbedu/e in !be seoood column below Ie .. any applicable Copayment
or DedoctibJe. 10 e.itber event, CopaJI'l<'Dts and/or Deductibles are payab!e 10 die Member
Doc!O< or Non-Member Pro\ider at !be time !be services are rendered and materials are
supplied.
PLAN BENEFITS
VISION CARE SERVICES
MEMBER DOCTOR
BEND]T
Covered in Fun
NON-MEMBER
BEl\lJ'IT
Up to S40.00
C~1ete initl3l vision analysis whick include.; an approptiate elWllinalioo 01 visual
funcoons. including the prescription 01 conective eye ... ear ",bere indicated.
subsequent regular vision examinations every 1.2 months.
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~~SERVICE~
yrsR)N CAPE MADllJMS NQN-MEMM'R
BENUIT
l.eII.!eo
single VISloo
Bifocal
Trifocal
.... vailable every 24 1IIOtlths.
Ccvered in Fun
Ccvered in Fun
ecvered in Fun
Covered in Fun
Up 10 $40.00
Up 10 $60.00
Up 10 $80.00
Up 10 $125.00
Frames Covered In Fun Up 10 545.00
up 10 Plan AIklwanu
.... vailabl. every 24 months.
Lenses and frames include socII prof=kl<W services as are necessary, .. hich .h.n
include:
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..------VI~~SERVK'E~ -----.....
CONTACT LENSJ<:S
In lieu of an other Plan Benefits aV3ilable hereunde, and ... bea a preocriptiOD change is
.-&JnD!Cd but in DO event IIlO<'t than on<:< in an, 24 monlll period.
Cootaa lenses IOgeIher with necessary professiooal services ",ill be
provided, with prioc authorization, only uDder one of the ~ing
eimunstaDces:
• Following eataract 5Urg~ .
• To correct extreme visuaI acuity problems tllaf eaDDO( be conecI<d ",ill! spectacle
leases
• CerIaln c:onditions of Anisometropia
• XetaIoconus
MEMBER DOCTOR BENEFIT
Exam and Materials
Covered in Fun
Subject 10 Copaymeotl
Deductible jf any
NON-MEMBER
SfNEFTI'
Up 10 S40.00 toward exam
Up 10 $210.00 IOward eoD"""
lens evaluation fee, finiag
costs and materials
ElectI: .. e· Cootaa lenses for pwposes other Illan uoder the ci1cumSl3DeeS above:
E>w., Covered in Full
Sa~ 10 Copaymenl/
Deductible if any
Materials Allowance"
Up to S40.00 ",ward exam
Up 10 $105.00 IOward eoalact
lens evaluation fee, fitting
costs and materials
"Materials anowance toward eoat!ct lens evaluation fee, fitting c'"'" and
materiaJs are equivalent llOOer 1he VSP progrun 10 spect;>cle lenses and frame.
COPAYMENIIDEPUCTmLE
The benefits de5cribed berein "'" available 10 eacll CQvered Per&><> from any participating VSP
Member DocIor at no OOSIIO the Covered Person. ~ Covered P=on muS! folJo .. · the proper
pro<:e<!Ureo by OOWning a VSP benefit form and presenting it to the doctor at the time of the
e xam ina6cwt.
A DEPUC'l1BLE AMOUNT OF TWENTY l)()!,M,RS <$2(UXl) SHAlL Ill: PAYABLE BY
TBECOVEREl) PERSON TO THE MEMBER DOCTOR AT THE TIME SERVICES ARE
RENDERED.
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,,__---V@IONSERVICE PIQN -----...
!.oW VISION BENU!T
lbe Low VlSio!! beoefll ;. available 10 c", .. red Persoru "'00 have severe visual prolllems !hal.
are DOl com:ctIble 1Vith regular Ie.,.... and ;. subject 10 prioc approval by VSP consulunts.
SapplemeDlary Testing
MEMJ!ER DOCTOR
B!NEFIT
Covered in Fun •
Complete low vision analysis and diagnosis which includes I comprehensive ,XaIIIiDmOa
cl visual fuDCtions, inclwfmg the prescription cl =<ive .y.wear or visioo aids .. bere
indjcated~
Supplemental Care 7H; clCOSI •
Subsequent low visioo therapy as Visually Necessary or Appropria~.
OJpaymetll
75" clthe authorized beoefits payible by VSP and 25:1i payable by Covered Person.
Benefit Maximum
lbe maximum beoefitavailable is $1,000.00 (excludiog cop;iymeotl every two yean .
• NON-MEMBER BENEFIT
Low VlSio!! beuefits secured from I Non-Member Provider are subject 10 the same tim.
limits and copaymeot ammgemeots as described above for I Member DocIor. The Covered
Penon shook! pay the Non-Member Pro_icier his run fee. Covered Penon 1I{'Ji be reimbursed
in """""'"'" "'Ill> an amount 00110 exceed .. bat VSP would pay • Member DocIOC in similar
circum ""nee< NOTE: lbere is DO assurance that this amount will be "U:hln the 25"
~ymetIl feature.
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----V~SERVICE~ -----....
EXCLUSIONS AND LIMITATIONS OF BENEFITS
PATIENT OPIlONS
This Pian is designed 10 cover visual zm's ruber than cOlIDletjc materials. \\'ben I Covered
Per.i<;D sekct! any of Ill<: following extrU, Ill<: ~lan .. ill pay !be basic cost of Ill<: allowed lenses,
and !be C<lvered PenIoo will pay tbe additiocaJ costs fO( the options.
I. Blended lenses.
2. Cootacllemes (except as ooted elsewhere berein.)
~. Ovemz., Iemes.
... _bromic lenses; tintf'<llemes except Pink 11 and Pi:!k 12.
S. Progressive multifocallenses.
6. The coating of tbe 1ens or lenses.
1. The lamfn;tting of the lens or lenses.
8. A fr.une thai costs more than tbe Pla., aIlowaoce.
9. CertailIIimitations <lII low vision care.
10. Cosmetic lenses.
11. Optional cosmetic processes.
12. llV (ultraviolet) prota.~ lenses.
NOTCOVERED
The.-.. is no benefiI fO( professioo.al services ()C materials connected "'ith:
I.
2.
J.
4.
Orthop<ics or vision training and any associated supplemental testing; plano Ieoses (less
than • :I:.~ diopw power); ()C two pair of glasses in lieu of bifocals;
Replacement of Jenses and frames furnished onder Litis Plan ""hie. are 10& or broke.,
except at the normal intervals ",ben services are otherwlse .vallable;
Medical or surgical treatment d the eyes;
Any eye exam.ination, or any corrective eyewear required by an employer as I coo.dition
d employment.
VSP MAY, AT ITS DlSCREIlON. WAIVE ANY OF THE P!.AN UMJTATIONS IF,IN THE
OPiNION OF YSP'S OPI'OMETRIC CONSULTANTS, IT IS NECESSARY FOR THE
VISUAL WEU'ARE OF THE COVERED PERSON.
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-----'\i.1IO~ SEID'ICE PION -----....
EXBIBITB
VISION SERVICE PLAN
SCJDDOLE OF ADVANCE PAYMENT A..'ID ADMINJSTRATIVE FEE
\'lSlON SERVICE PLAN ("VSP") shall be cntitJed 10 recei>. amounts clue for each IDOIllh on
behalf c{ eaclI Enrollee and hisiher Eligible Depenc!ent>, if m, in !hie amounts·specified below:
ADVANCE PAYMENT
ADMlNISTRAllVE FEE
$ S,946.00
In OF MONTHLY CLAIMS
NOTICE: The amow>t clue un<iet Ibis Plan is subject 10 change, upoo rene1Ial, after Il>c cOO
c{ !be Initial Plan Tenn oc any subsequent Plan Term, 01 upon change c{ !be Scbedule of
Benefits 01 • change in any O!het term, oc cooditioos of :be Plan.
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---v1ilON SEHVlCE PIllN
VISION SERVICE PLAN
ADDITIONAL BENEFIT
SAFETY EYEWEAR
COVERED PERSONS WHO MEET mE ElJGIBlUTY REQUIREMI!NTS OOTllNED
UNDER "EI.IGIBnlTY" ON mE AITACHED SAH:TY EYEW1:AR SCHEDULE OF
BENEFITS OF THIS ADDENDUM AND WHO RE.QUIn SAFET'i EYEWEAR DUE TO
'mE NATURE OF THEIR WORK SHAll.. BE EUGIBLE FOR mE SAFETY EYEWEAR
PROGRAM.
SERVICES FROM MEMBER DOCTORS
MATERIALS
Materials will be certified as safe for • wod: environment by meeting the =ssary leSt
requirements as set forth by ANSI (American Natioruti Standards Ins6tu!e).
A. lENSES • The Member Doctor will order proper lenses necessary for the Covered
Penon'. benefit. Sue. lenses mUSl meet the following conditions:
• be no less than 3mm at the IhlnnesI poiJtt;
• be impact IeSIed witIJ • one·inc~ steel ball dropped from • bo1gb! of 50 inches:
and
• be engraved by the manufacturer thai iI: is • safety lens.
&<:11 c.wered Penon is entitled 10 new safely lenses _ on the frequency as indiCllell
on the anaclled SAFETY EYEWEAR SCHEDULE OF BENEFITS.
B. FRAMES -New safety IJames will be pro>ided based on the frequency as indicated 00
the anaclled SAfETY EYEWEAll SCHEDULE OF BENEFITS. SlICk frame. mIL"
meet the lollowing conditions:
• flave • Z·87 stamp on the front and temples; and
• be coostrucIed. so tba1.. if impacted from the front, the lens ... ill nc< COlD< 001
through the bad: of the fJame.
Illlddition. the frame may include. plastic 01' roesh side shield, as specifted by c,ruin
industry stuKIards.
VSP reserves the rigbt 10 limit the cost of the IJames provided by its Member Dc>ctor.
onder the plan. The allowance shaJl be publisbed periodically by VSP 10 its Member
Dc>ctor..
IF mE COVERED PERSON WISHES TO SELOCT A MORE EXPENSIVE FRAME
1HAN tHAT AU.OWED UNDER TIlE PROORAM. THE COST DlFFERENCE
SHAlL BE BY AGREEMENT BETWEEN THE COVERED PERSON AND TIlE
DOCTOR.
1
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" ...
~IONSERVICE~ --_ .........
DmuCfIBLE
The bendXs described herein on: • vailable 10 eacl! Covered Persoo eligible lor the Safety
Eyewear beoefit from lily pankipating Member DocIor at no .:ost 10 the CovetOd Person,
provided Covered Persoo IoIlow. the proper procedures by obIai.'1ing I benefit form and
presenling illO the doctor in advance.
HOWEVER. THERE MAY BE A DEDUCTIBLE AMOUNi AS INDICATED ON TIlE
ATTACHED SAFETY EYEWEAR SCHEI>ULE OF BENUlTS. PAYABlE BY TIlE
COVERED PERSON TO THE MEMBER DOCTOR AT THE TIME OF SF..IlVlCfS.
2
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,..-----~Io.~SERVICE~" ----...
gO Jl!l.JONS AND UMITAI1QNS OF BWf.FITS
SAFETY EYEV>'EAll BENEfIT ONLY
PA'flENT OP1lONS
This Vzsioe Service P1an is designed to cover. visa' nmb; rather tIwl.ysme6c ma,?riak. When
I Covered Pmon selects my of !be foJlowmg eldras, !be plan "iD pay the basic cost of !be
allowed lenses, and the Ccyered Person .. ill pay !be additio!W costs foc the option •.
I. Blended \cmeS
2. Q\lenize lenses
3. Progressive mriltifO<allen.ses
4. Pboto<hromic lenses; tinled 1en= except Pink II and Pink 12
S~ Coated or laminated leases
6. A ftame Ilw COOlS """" to'w! Ill. plan allowance
1. Cosmetic lenses
8. Opciooal rosmeti<: proceS>eO
9. IN (u""'violet) protocted Iense<
NaT COVElUlD
'Jbere is 00 benefit Co< profiossioDal services 0< lIUIIerials coonected willl:
I. Suboonnal Y1sion aids;
2. 0rtII0p0cs 0< YisioD tnming and any a..<sociated supplemental test!ng; plaDo Ien;es, 0.
two pair of glasses in lieu of bifocals;
3. CooIa<:t lenses;
4. ~ of lenses and frames fumisbed under this plan "'Irlcll an: lost 0< broke"
except at the oormal internls ",bet! servkos "'0 otherwise available;
5. Medical 0< surgi;:al treatment of !be eyes;
6. Any eye e.xmUnation,. or any c.orJUtive eye wear, required by an employer as a.
"""clition 0{ employment;
1. Service< provided by I non-member doclOr.
VSPMAY, AT ITS DlSCREI'ION, WAIVE ANY OF THE PLANUMITAllONS IF,iN THE
OPINION OF OUR. OPTOMETRlC CONSULTANTS, TInS IS NECESSARY FOR. THE
VISUAL WEl.FARE OF THE COVERED faSON.
T "flit"_
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I
___ -----fil~/ISIO"l SERVICE~
WGOOlD"
For purpo<e< o(!his Plan. eligible employ= shaIi be as defu>ed by Group.
Ilepen<klll .:overage is not providod ll~ !his benefit.
SERytcrS mOM MWI!ER DOCTORS
Fnme
fUO!!FNcy
Every twelve (12) months
Every twenty-four (24) months