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HomeMy WebLinkAboutReso 94-355 - Approve entering into 2 yr contract with Vision Serv Plan effective 01-01-95 RESOLUTION NO. 94-�S_S_ A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF REDDING APPROVING ENTERING INTO A TWO-YEAR VISION SERVICE PLAN CONTRACT, EFFECTIVE JANUARY 1, 1995, BETWEEN THE CITY OF REDDING AND VISION SERVICE PLAN (VSP) , IN WHICH VSP WILL ADMINISTER THE CITY'S SELF-INSURED VISION SERVICE PLAN; AND AUTHORIZING THE MAYOR TO SIGN. IT IS HEREBY RESOLVED that the City Council of the City of Redding hereby approves entering into a two-year contract with Vision Service Plan, effective January 1, 1995, to administer the City' s self-insured Vision Service Plan, with the City paying $1. 65 per employee per month. BE IT FURTHER RESOLVED that the Mayor is hereby authorized and directed to sign the contract with Vision Service Plan, a true copy of which is attached hereto and made a part hereof ; and the City Clerk is hereby directed to attest the signature of the Mayor and to impress the official seal of the City of Redding thereto. I HEREBY CERTIFY that the foregoing Resolution was introduced, read, and adopted at a regular meeting of the City Council on the 20th day of December, 1994, by the following vote: AYES: COUNCIL MEMBERS: P. Anderson, Kehoe, McGeorge, Murray and R. Anderson NOES: COUNCIL MEMBERS: None ABSENT: COUNCIL MEMBERS: None ABSTAIN: COUNCIL MEMBERS: None R BERT C. ANDERSON, Mayor City of Redding X) A'''ITEST: FORM PPROVED: s CONNIE STROHMAY6, City Clerk ALL A. HAYS, City Attorney (-f( AAL RENEWAL NOTICE VSP ve 0 October 31, 1994 VISIM SERVICE CITY OF REDDING 760 Parkview Avenue Redding, CA 96001 ATTENTION: James G. Bristow, Dir. Personnel Your VSP vision care experience has been reviewed in anticipation of the upcoming renewal. As a result of our analysis, your administrative fee and renewal period have been revised as follows: GROUP NAME: CITY OF REDDING GROUP#: 00237134 RENEWAL PERIOD: January 1, 1995-December 31, 1996 CURRENT RATE: $1.45 NEW RATE: $1.65 ACCOUNT EXECUTIVE: Vicki Burt, Account Executive TELEPHONE NUMBER: (800) 852-7600 Vision Service Plan appreciates your business and strives to provide complete satisfaction with our service. If you have any questions or wish to discuss this renewal notice,please contact your VSP Account Executive. *************************************************************************************** Please sign and return this portion of the notice in the enclosed envelope to acknowledge acceptance of the renewal. GROUP NAME: CITY OF REDDING GROUP#: 00237134 RENEWAL PERIOD: January 1, 1995-December 31, 1996 RENEWAL RATE: $1.65 Authorized Group Representative Signature cc: Charles E. Bertolina CEB BUSINESS INSURANCE SERVICE �,_ 7 Quail Court, Suite 313 Walnut Creek, CA 94596 VAION SERVICE FCRN VISION SERVICE PLAN 3333 Quality Drive Rancho Cordova, California 95670 GROUP VISION CARE PLAN ADMINISTRATIVE SERVICES PROGRAM Group Name CITY OF REDDING Group Number 00237134 State of Delivery CALIFORNIA Effective Date JANUARY 1, 1995 Amounts Due Date FIRST DAY OF MONTH Plan Term TWENTY-FOUR (24) MONTHS In consideration of the statements and agreements contained in the Group Application and in consideration of payment by the Group of the amounts due as herein provided, VISION SERVICE PLAN ("VSP") agrees to provide certain individuals under this Group Vision Care Plan ("Plan") the benefits provided herein, subject to the exceptions, limitations and exclusions hereinafter set forth. This Plan is delivered in and governed by the laws of the state of delivery and is subject to the terms and conditions recited on the subsequent pages hereof, which are a part of this Plan. R ger J. Valine, President -i- VSP-GVCP-ASP-12/92 10/31/94 cla VAON SERVICE PLfN VISION SERVICE PLAN GROUP VISION CARE PLAN ! ADMINISTRATIVE SERVICES PROGRAM TABLE OF CONTENTS TITLE PAGE I. DEFINITIONS 1 II. TERM, TERMINATION, AND RENEWAL 4 III. OBLIGATIONS OF VSP 5 IV. OBLIGATIONS OF THE GROUP 7 V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN 9 VI. ELIGIBILITY FOR COVERAGE 10 VII. CONTINUATION OF COVERAGE 12 VIII. ARBITRATION OF DISPUTES 13 IX. NOTICES 14 X. MISCELLANEOUS 15 ATTACHMENTS EXHIBIT A - SCHEDULE OF BENEFITS EXHIBIT B - SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE SPLN 4/93 VISIONSE RVICE PL*N VISION SERVICE PLAN GROUP VISION CARE PLAN 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 where by 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. ANISOMETROPIA: A condition of unequal refractive state for the two eyes, one eye requiring a different lens correction than the other. 1.05. BENEFIT FORM: A form issued by VSP identifying the individual named thereon as a Covered Person of VSP, and identifying those Plan Benefits to which Covered Person is entitled. 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. DEDUCTIBLE: An amount which is paid by or on behalf of a Covered Person toward Plan Benefits. It applies separately to the Plan Benefits incurred by each Covered Person. Plan Benefits will be paid for only those expenses, services, or materials which are more than the deductible amount. -1- SPLN 4/93 .i ION SERVICE 1.10. 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. 1.11. EMERGENCY CONDITION: A condition which requires the Covered Person or Eligible Dependents to seek immediate vision care either from a VSP Member Doctor or Non-VSP Member Provider. 1.12. ENROLLEE: An employee or member of Group who meets the criteria for eligibility specified under VI. ELIGIBILITY FOR COVERAGE. 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 or members, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan Benefits in accordance with the terms of such Plan. 1.16. KERATOCONUS: A developmental or dystrophic deformity of the cornea-in which it becomes coneshaped due to a thinning and stretching of the tissue in its central area. 1.17. 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. -2- SPLN 4/93 VAON SERVICE PJ- N 1.18. 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. 1.19. PLAN ADMINISTRATOR: The person specifically so designated on the application, or if an administrator is not so designated, the Group. 1.20. 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. 1.21. RENEWAL DATE: The date on which the Plan shall renew, or expire if proper notice is given. 1.22. 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. 1.23. 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/her to Plan Benefits. 1.24. VISUALLY NECESSARY OR APPROPRIATE: Services and materials medically or visually necessary to restore or maintain a patient's visual acuity and health and for which there is no less expensive professionally acceptable alternative. -3- SPLN 4/93 VMION SERVICE PL*N II. TERM, TERMINATION, AND RENEWAL 2.01. This Plan shall become effective on the date first above stated, and shall remain in effect for the Plan Term. At the expiration of the Plan Term, it shall 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 such party is unwilling to renew the Plan. If such notice is given, the Plan shall expire at 12:00 midnight on the last day of the Plan Term unless the parties reach mutual agreement on its renewal. 2.02. In the event of termination of this Plan by either party, Group agrees to provide funds for payment pursuant to benefit forms issued prior to the termination date, provided such benefit forms are filed with VSP within six (6) months after termination of this Plan. -4- S SPLN 4/93 VAON SERVICE PLIN III. OBLIGATIONS OF VSP 3.01. Coverage of Covered Persons: VSP will enroll for coverage each eligible Enrollee, and his/her Eligible Dependents, if dependent coverage is provided, all of whom shall be referred to upon their enrollment as "Covered Persons." To institute coverage, Group may be required by VSP to complete and sign a Group Application and forward such application to VSP, along with information regarding Enrollees and Eligible Dependents, and all applicable amounts due. (Refer to VI. ELIGIBILITY FOR COVERAGE for further details.) Following the enrollment of the Covered Persons, VSP will make available to all Covered Persons a Vision Care Brochure. Such Brochure will summarize the terms and conditions set forth in 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 chooses to receive Plan Benefits from a Non-Member Provider) VSP shall provide Covered Persons such Plan Benefits listed in the Schedule of Benefits, Exhibit A hereto, as may be Visually Necessary or Appropriate, subject to any limitations, exclusions, deductibles, or copayments therein stated. When a Covered Person desires to receive Plan Benefits, the Covered Person shall contact VSP. VSP shall forward a Benefit Form to the eligible Covered Person, for use in receiving Plan Benefits from a Member Doctor, or for reimbursement when Plan Benefits are received from a Non- Member Provider: Benefit Forms shall be issued to Covered Persons by VSP in accordance with the latest eligibility information furnished by Group. Any Benefit Form so issued by VSP shall constitute a certification to the VSP Member Doctor that payment will be made, and VSP shall not be held liable to Group for any Benefit Forms issued in error, provided they were issued in accordance with these provisions. Covered Persons are required to obtain the Benefit Form prior to seeking Plan Benefits only in cases in which the Covered Person intends to seek Plan Benefits from a Member Doctor (See Section 5.03 for further details). VSP shall process i requests for Benefit Forms which shall be forwarded to VSP by Covered Persons, Group, or by the Plan Administrator. VSP shall reimburse Member Doctors for Plan Benefits provided to -5- SPLN 4/93 VA ON SERVICE MAN Covered Persons, or reimburse Covered Persons for Plan Benefits received from Non-Member Providers, less any applicable deductible or copayment, within a reasonable time but not more than forty-five (45) days after VSP has received the completed Benefit Form from either its Member Doctor or Covered Person. VSP shall furnish to Group on a monthly basis, a list of all benefits paid pursuant to this Plan. 3.03. Determination of Visual Necessity: Plan Benefits are covered only when and to the extent that they are deemed Visually Necessary or Appropriate for the proper treatment of a Covered Person's condition. Questions involving necessity or appropriateness of treatment shall be decided by the Member Doctor (or Non-Member Provider) responsible for the Covered Person's care and are subject to review by VSP. Any objections of a Covered Person relating to such decisions may be made to VSP at the address given herein. 3.04. Provision of Information to Covered Persons: VSP shall make available to the Covered Persons necessary information describing Plan Benefits and the appropriate method for using them. A copy of this Plan shall be placed with Group and also will be made available at the offices of VSP for any Covered Persons who wish to inspect or copy it. VSP shall provide to Covered Persons an updated list of the Member Doctors' names, addresses, and telephone numbers. 3.05. Preservation of Confidentiality: VSP shall hold in strict confidence all confidential matters and exercise its best efforts to prevent any of its employees, Member Doctors, or agents, from disclosing any confidential matter, except to the extent that such disclosure is necessary to enable any of the above to perform their obligations under this Plan, including but not limited to sharing information with medical information bureaus, or as may otherwise be required by law. 3.06. Emergency Vision Care: In emergency cases, when vision care is necessary, Covered Persons may obtain Plan Benefits by contacting a Member Doctor or Non-Member Provider. Reimbursement is subject to the same provisions as stated elsewhere herein. -6- SPLN 4/93 VAON SERVICE PL*N IV. OBLIGATIONS OF GROUP 4.01. Identification of Eligible Enrollees: An Enrollee is eligible for coverage under this Plan, if he/she satisfies the enrollment criteria specified in Paragraph 6.41(a) and/or as mutually agreed to by VSP and Group. By the effective date of this Plan, Group shall provide VSP with a listing, in a form approved by VSP of all of its Enrollees who are eligible for coverage under this Plan as of that date and a designation of family status for each such Enrollee, if dependent coverage is provided. Thereafter, Group shall supply to VSP on or before the last day of each month, in a form approved by VSP a listing of all Enrollees, with a designation of family status, to be added to or deleted from VSP's coverage rosters for the succeeding month. 4.02. Benefit Costs and Advance Payment: Group shall provide all funds necessary to pay the covered costs of professional services and ophthalmic materials (Plan Benefits) furnished to 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 benefit costs for one (1) month. Group agrees to pay the actual costs of benefits on a monthly basis within ten (10) days after receipt of VSP's statement of benefits paid. The Advance Payment amount may be adjusted each Plan term if the average of monthly benefit costs 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. -7- SPLN 4/93 AllON SERVICE PAN VSP may change the Administrative Fee shown on the attached Schedule of Advance Payment and Administrative Fee, Exhibit B, by giving the Group at least sixty (60)days advance written notice. Change will not be made more often than once during any twelve (12) month period unless there is a change in the Schedule of Benefits or a change in any other terms and conditions of the Plan. Notwithstanding the above, VSP reserves the right to increase amounts due hereunder 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 amounts 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 said grace period, this Plan shall remain in full force and effect for all Covered Persons covered hereunder. 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 all Plan Benefits provided to Covered Persons after the last period for which amounts due were fully paid, including the grace period. 4.05. Other Information to be Provided: Group shall furnish to VSP monthly during the effective period of this Plan such information as may reasonably be required by VSP for the purposes of this Plan, including listings of new Enrollees, terminations of eligibility, and changes in the family status of covered Enrollees. Such information shall be supplied in a form specified by VSP. In addition, Group shall, when requested, make available for inspection by VSP such records as may have bearing on the coverage of Covered Persons under this Plan. 4.06. Distribution of Required Documents: Group agrees to distribute to Enrollees, any disclosure forms, plan summaries or other material that may be required to be given to plan subscribers by any regulatory authority. Such materials shall be distributed by Group to Enrollees no later than thirty (30) days after the receipt thereof. -8- SPLN 4/93 VAON SERVICE MAN V. OBLIGATIONS OF COVERED PERSONS COVERED UNDER THE PLAN 5.01General: By this Plan, Group makes coverage available to its Enrollees and their Eligible Dependents, if dependent coverage is provided. However, this Plan may be amended or terminated by agreement between VSP and Group without the consent or concurrence of the Covered Persons. This Plan, and all Exhibits and all attachments and any amendments hereto, shall constitute VSP's sole and entire undertaking to Covered Persons covered under this Plan. All persons covered as Covered Persons under this Plan shall have the following obligations as a condition of their coverage: 5.02. Deductibles and Copayments for Services Received: Where, as indicated on the Schedule of Benefits, Exhibit A hereto, deductibles and/or copayments are required for certain Plan Benefits, these deductibles and/or copayments shall be the personal responsibility of the Covered Person receiving the care and must be paid to the vision care provider (whether a Member Doctor or Non-Member Provider) on the date the services are rendered. 5.03. Approval of Services: A Covered Person must receive approval before visiting a Member Doctor. Such approval is received by obtaining from VSP a Benefit Form. Should the Covered Person receive Plan Benefits from a Member Doctor without such approval, 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. 5.04. Complaints and Grievances: Time of Action: Covered Persons shall report any complaints and/or grievances to VSP at the address given herein. No action in law or in equity shall be brought to recover on the Plan prior to the expiration of sixty (60) days after the Benefit Form and any applicable invoices have been filed with VSP. No such action shall be brought after the expiration of three (3) years from the last date that the Benefit Form and any applicable invoices may be submitted to VSP, in accordance with the terms of this Plan. -9- PLN 4/93 VRION SERVICE PAN VI. ELIGIBILITY FOR COVERAGE 6.01. Eligibility Criteria: Individuals will be accepted for coverage hereunder only upon meeting all the applicable requirements set forth below. (a) Enrollees: To be eligible for coverage, a person must: (1) currently be an employee or member of the Group, and (2) meet the criteria established in the coverage criteria mutually agreed upon by Group and VSP. (b) Eligible Dependents: If dependent coverage is provided, the persons eligible for coverage as dependents shall include: (1) the legal spouse of any Enrollee, and (2) any unmarried child of an Enrollee, including any natural child from the moment of birth, legally adopted child from the moment of placement in the residence of the Employee, 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 attained the age of nineteen (19) years, or (B) who is chiefly dependent upon the Enrollee for support, has not yet attained the age of twenty-four (24) years, and is currently enrolled as a full-time student in good standing actively pursuing a degree or certificate at a recognized educational institution. (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 so long as he remains a dependent and the Enrollee's coverage remains in force; PROVIDED that satisfactory proof of the dependent's incapacity can be furnished to VSP within thirty-one (31) days of the date such dependent's coverage would have otherwise terminated or 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: _10- 10/31/94 10-10/31/94 cla VAON SERVICE PLRN (a) in the case of an Enrollee, the individual's name and Social Security Number has been reported by the Group to VSP in the manner provided hereunder, and (b) in the case of changes to a dependent's status, the change has been reported by the Group to VSP in the manner provided herein. As indicated in Paragraph 4.05 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 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 Change of Participation Requirements. Contribution of Fees, and Eligibility Rules: Composition of the Group, percentage of Enrollees covered under the Plan, and eligibility requirements, are material to VSP's obligations under this Plan. During the term of this Plan, Group may not change its composition, percentage of Enrollees covered, or eligibility requirements, in any way which affects VSP's obligations hereunder unless VSP consents to such change in writing. VSP may require the Group to make written request for any such change at least sixty (60) days prior to the proposed effective date of the change. Nothing herein shall limit Group's ability to add Enrollees and/or Eligible Dependents in accordance with the terms of this Plan. 6.04. Change in Family Status: In the event 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.) written notice in a form acceptable to VSP is to be given to VSP by the Covered Person, or by someone else acting on the Covered Person's behalf, within thirty-one (3 1) days of such change. If such notice is given, the change in the Covered Person's status will become effective on the first day of the month following the request for change, or at such later date as may be requested by or on behalf of the Covered Person. A newborn will be covered during the thirty-one (31) day period after birth. -11- SPLN 4/93 3 VION SERVICE PLAS; Fn'71VII. CONTINUATION OF COVERAGE: . . BRA: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that under certain circumstances health plan benefits available to an eligible Enrollee and his or her dependents be made available for purchase by said persons upon the termination of employment of said Enrollee, or the termination of the relationship between said Enrollee and his or her dependents. If, and only to the extent, COBRA applies to the parties to this Plan, VSP shall make the statutorily-required continuation coverage available for purchase in accordance with COBRA. -12- PLN 4/93 VAON SERVICE PL*%; VIII. ARBITRATION OF DISPUTES: Fn98.. 1. 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, allowing 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. The procedure for arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration Association. i -13- PLN 4/93 VAON SERVICE MIN IX. NOTICES 9.01. Any notices required 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. Notwithstanding the above, any notices may be hand-delivered by either party to an appropriate representative of the party, with the burden being on the part effecting such hand-delivery, to prove, if questioned, that such delivery was made. i -14- PLN 4/93 VAON SERVICE PYRN 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. 10.02. Indemnity: VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors, officers, agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal fees) of any nature whatsoever arising from the failure of VSP, its officers, agents or employees, to perform any of the activities, duties or responsibilities specified herein. Group agrees to indemnify, defend and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal fees) of any nature whatsoever arising or resulting from the failure of Group, its officers or employees to perform any of the duties or responsibilities specified herein. 10.03. Liability: 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. Right to Refect Claims: VSP reserves the right to reject any and all claims for services or benefits which are filed with it more than one hundred eighty (180) days after completion of services. 10.05. Assignment: Neither this Plan nor any of the rights or obligations of either of the parties hereto may be assigned or transferred, except as may be expressly authorized and provided herein, without the prior written consent of both parties hereto. 10.06. Severability: Should any provision of this Plan be declared invalid, the remaining provisions shall remain in full force and effect. -15- PLN 4/93 J VAON SERVICE PLf& 10.07. Choice of Law: While recognizing that question(s) and dispute(s) hereunder are rttnbe resolved by arbitration, 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. 10.08. 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. -16- PLN 4/93 VIRION SERVICE MRN EXHIBIT A VISION SERVICE PLAN SCHEDULE OF BENEFITS PLAN A 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. 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 Copayment and/or Deductible as stated below. When Plan Benefits are 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 Copayment or Deductible. In either event, Copayments and/or Deductibles are payable to the Member. Doctor or Non-Member Provider at the time the services are rendered and materials are supplied. PLAN BENEFITS MEMBER DOCTOR NON-MEMBER BENEFIT BENEFIT VISION CARE SERVICES Vision Examination Covered in Full Up to $40.00 Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of corrective eyewear where indicated. Subsequent regular vision examinations every 12 months. -1- VIS ON SERVICE PJI%;, VISION CARE MATERIALS MEMBER DOCTOR NON-MEMB ERR BENEFIT BENEFIT Lenses Single Vision Covered in Full Up to $40.00 Bifocal Covered in Full Up to $60.00 Trifocal Covered in Full Up to $80.00 Lenticular Covered in Full Up to $125.00 Available every 24 months. Frames Covered in Full Up to $45.00 up to Plan Allowance Available every 24 months. Lenses and frames include such professional services as are necessary, which shall include: 1. Prescribing and ordering proper lenses; 2. Assisting in the selection of frames; 3. Verifying the accuracy of finished lenses; 4. Proper fitting and adjustment of frames; 5. Subsequent adjustments to frames to maintain comfort and efficiency; 6. Progress or follow-up work as necessary. -2- VAI0N SERVICE MAN CONTACT LENSES In lieu of all other Plan Benefits available hereunder and when a prescription change is warranted but in no event more than once in any 24 month period. Necessary - Contact lenses together with necessary professional services will be provided, with prior authorization, only under one of. the following circumstances: • Following cataract surgery 0 To correct extreme visual acuity problems that cannot be corrected with spectacle lenses 0 Certain conditions of Anisometropia • Keratoconus MEMBER DOCTOR NON-MEMBER BENEFIT BENEFIT Exam and Materials Up to $40.00 toward exam Covered in Full Up to $210.00 toward contact Subject to Copayment/ lens evaluation fee, fitting Deductible if any costs and materials Elective - Contact lenses for purposes other than under the circumstances above: Exam Covered in Full Up to $40.00 toward exam Subject to Copayment/ Deductible if any Materials Allowance* Up to $105.00 toward contact lens evaluation fee, fitting costs and materials *Materials allowance toward contact lens evaluation fee, fitting costs and materials and equivalent under the VSP program to spectacle lenses and frame. COPAY`iENT/DEDUCTIBLE The benefits described herein are available to each Covered Person from any participating VSP Member Doctor at no cost to the Covered Person. The Covered Person must follow the proper procedures by obtaining a VSP benefit form and presenting it to the doctor at the time of the examination. A DEDUCTIBLE AMOUNT OF * SHALL BE PAYABLE BY THE COVERED PERSON TO THE MEMBER DOCTOR AT THE TIME SERVICES ARE RENDERED. *FIVE DOLLARS ($5.00) or TWENTY-FIVE DOLLARS ($25.00) AS DETERMINED BY GROUP. { i I -3- i VAION SERVICE PLIN LOW VISION BENEFIT The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with regular lenses and is subject to prior approval by VSP consultants. MEMBER DOCTOR NON-MEMBER BENEFIT BENEFIT Supplementary Testing Covered in Full Complete low vision analysis and diagnosis which includes a comprehensive examination of visual functions, including the prescription of corrective eyewear or vision aids where indicated. Supplemental Care 75% of Cost Subsequent low vision therapy as Visually Necessary or Appropriate. Copayment 75% of the authorized benefits payable by VSP and 25% payable by Covered Person. Benefit Maximum The maximum benefit available is $1,000.00 (excluding copayment) every two years. * NON-MEMBER 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. 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. -4- V11I0N SERVICE PLTN EXCLUSIONS AND LIMITATIONS OF BENEFITS PATIENT OPTIONS This Plan is designed to cover visual needs rather than cosmetic materials. When a Covered Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses, and the Covered Person will pay the additional costs for the options. 1. Blended lenses. 2. Contact lenses (except as noted elsewhere herein.) 3. Oversize lenses. 4. Photochromic lenses; tinted lenses except Pink #1 and Pink #2. 5. Progressive multifocal lenses. 6. The coating of the lens or lenses. 7. The laminating of the lens or lenses. 8. A frame that costs more than the Plan allowance. 9. Certain limitations on low vision care. 10. Cosmetic lenses. 11. Optional cosmetic processes. 12. UV (ultraviolet) protected lenses. NOT COVERED There is no benefit for professional services or materials connected with: 1. Orthoptics or vision training and any associated supplemental testing; piano lenses (less than a ±.38 diopter power); or two pair of glasses in lieu of bifocals; 2. Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when services are otherwise available; 3. Medical or surgical treatment of the eyes; 4. Any eye examination, or any corrective eyewear required by an employer as a condition of employment. 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. -5- VRION SERVICE Ptl� EXHIBIT B VISION SERVICE PLAN SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE VISION SERVICE 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 $ 7,830.00 ADMINISTRATIVE FEE $ 1.65 PER ELIGIBLE EMPLOYEE, PER MONTH NOTICE: The amount due under this Plan is subject to change, upon renewal, after the end of the Initial Plan Term or any subsequent Plan Term, or upon change of the Schedule of Benefits or a change in any other terms or conditions of the Plan.