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11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 11111111111111111111111111111111111111010101111111111111111111111111111111111111111111111111111111111111111111111111111111111111 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111010101040000002701ffff030000000000}\par}}}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \par \par \par }\pard \ltrpar\ql \li1440\ri0\widctlpar\tx5940\wrapdefault\faauto\rin0\lin1440\itap0 {\rtlch\fcs1 \af43\afs16 \ltrch\fcs0 \f43\fs16\insrsid8529593 \tab }{\rtlch\fcs1 \af43\afs16 \ltrch\fcs0 \f43\fs16\cf17\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Vision Care for Life \par }\pard \ltrpar\qr \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trrh1440\trleft-144\tpvpg\tphpg\tposx2736\tposy5184\tdfrmtxtLeft144\tdfrmtxtRight144\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8208\clpadl72\clpadt144\clpadb72\clpadr144\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx8064\pard \ltrpar\ql \fi-2880\li2880\ri0\nowidctlpar\intbl \tx2880\pvpg\phpg\posx2736\posy5184\dxfrtext144\dfrmtxtx144\dfrmtxty0\wraparound\faauto\rin0\lin2880 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\cf1\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Client Name:\tab 91ÖÆƬ³§ \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Client Number:\tab 30051106 \par \hich\af43\dbch\af31505\loch\f43 Effective Date:\tab JANUARY 1, 2019\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow\ts11\trrh1440\trleft-144\tpvpg\tphpg\tposx2736\tposy5184\tdfrmtxtLeft144\tdfrmtxtRight144\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8208\clpadl72\clpadt144\clpadb72\clpadr144\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx8064\row }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \par \par \par \par \par \par \par \par \par }{\rtlch\fcs1 \ab\af43\afs36 \ltrch\fcs0 \b\f43\fs36\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 EVIDENCE OF COVERAGE \par }{\rtlch\fcs1 \af43\afs28 \ltrch\fcs0 \f43\fs28\insrsid8529593 \par \par \par \par }\pard \ltrpar\qc \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Provided by: \par \par }\pard \ltrpar\qc \li0\ri0\widctlpar\tqc\tx4680\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs28 \ltrch\fcs0 \b\f43\fs28\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 VISION SERVICE PLAN INSURANCE COMPANY \par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 3333 Quality Drive, Rancho Cordova, CA 95670 \par }\pard \ltrpar\qc \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 (916) 851-5000 (800) 877-7195 \par \par \par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trrh740\trleft-144\tpvpg\tphpg\tposx864\tposy14400\tdfrmtxtRight144\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10656\clpadl72\clpadt144\clpadb72\clpadr144\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10512\pard \ltrpar\ql \li0\ri0\nowidctlpar\intbl\tx9360\pvpg\phpg\posx864\posy14400\wraparound\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs16 \ltrch\fcs0 \f43\fs16\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 EOC MO 0810 \tab 12/19/18 Syr\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow\ts11\trrh740\trleft-144\tpvpg\tphpg\tposx864\tposy14400\tdfrmtxtRight144\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb \brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10656\clpadl72\clpadt144\clpadb72\clpadr144\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10512\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 1\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\qj \li0\ri0\sl-220\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Notice to Client: In the \hich\af43\dbch\af31505\loch\f43 event this document is used to develop a Summary Plan Description, complete the information below, as applicable. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \par \hich\af43\dbch\af31505\loch\f43 NAME OF CLIENT:\tab \par \par \hich\af43\dbch\af31505\loch\f43 NAME OF PLAN:\tab \par \par \hich\af43\dbch\af31505\loch\f43 PRIMARY ADDRESS OF CLIENT:\tab \par \par \hich\af43\dbch\af31505\loch\f43 PLAN ADMINISTRATOR: \par \par \hich\af43\dbch\af31505\loch\f43 ADDRESS:\tab \par \par \hich\af43\dbch\af31505\loch\f43 PHONE NUMBER:\tab \par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 This Evidence of Coverage is a summary of the Policy provisions and is presented as a matter of general information only. It is not a substitute for the provisions of the Policy itself. In the event of any dispute between this Evidence of Coverage and t \hich\af43\dbch\af31505\loch\f43 h\hich\af43\dbch\af31505\loch\f43 e Policy, the provisions of the Policy will prevail. A copy of the Policy will be furnished on request. If any changes are made to this document by anyone other than VSP, VSP disclaims responsibility for such changes and cannot guarantee this document w \hich\af43\dbch\af31505\loch\f43 i\hich\af43\dbch\af31505\loch\f43 ll comply with any statutory requirements including but not limited to ERISA. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 ELIGIBILITY FOR COVERAGE \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Enrollees}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 : To be covered, a person must currently be an employee or member of the Client, and meet the coverage criteria established by Client. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Eligib\hich\af43\dbch\af31505\loch\f43 le Dependents}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 : Any dependent of an Enrollee of Client who meets the eligibility criteria established by Client, if such dependent coverage is provided. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 2\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 HOW TO USE THIS PLAN \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 VSP provides Plan Benefits to Covered Persons based on the level of coverage purchased by the Client. Refer to the Schedule of Benefits and Additional Benefit Rider (if applicable) for specific Plan Benefits. \par \par }\pard \ltrpar\qj \fi720\li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 1. Contact VSP to obtain a list of participat\hich\af43\dbch\af31505\loch\f43 ing providers, and/or to view available benefits, (see below for contact information). \par }\pard \ltrpar\qj \fi720\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 2. Contact a VSP Preferred Provider\hich\f43 \rquote \loch\f43 s office to schedule an appointment and indicate that Covered Person is a VSP member. Should Covered Persons fail to identify thems \hich\af43\dbch\af31505\loch\f43 elves as VSP members, Plan Benefits shall be limited to those of an Open Access Provider, if such Plan Benefits are available. \par \par \hich\af43\dbch\af31505\loch\f43 3. Once the appointment is made, the VSP Preferred Provider will obtain benefit verification from VSP. The VSP Preferred Provid\hich\af43\dbch\af31505\loch\f43 er will bill VSP directly and the Covered Person is responsible for payment of any applicable Copayments, non-covered services or materials, or amounts which exceed plan allowances, and annual maximum benefits. \par }\pard \ltrpar\ql \fi720\li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \fi720\li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 4. If the Policy includes Plan Benefits for\hich\af43\dbch\af31505\loch\f43 Open Access Providers, Covered Person may be responsible for paying for all services and/or materials in full and submitting a claim to VSP. All reimbursement will be in accordance with the Open Access Provider fee schedule, less any applicable Copaymen \hich\af43\dbch\af31505\loch\f43 t\hich\af43\dbch\af31505\loch\f43 . Obtaining services from an Open Access Provider will typically result in higher out of pocket expenses for Covered Persons. Covered Persons must submit claims to VSP within 180 calendar days from the date services are rendered and/or materials provide \hich\af43\dbch\af31505\loch\f43 d\hich\af43\dbch\af31505\loch\f43 . In the event it is not reasonably possible to submit claims within this period, claims must be submitted as soon as reasonably possible. However, in no event, except in the absence of legal capacity of the Covered Person, may claims be submitted later \hich\af43\dbch\af31505\loch\f43 \hich\af43\dbch\af31505\loch\f43 than fifteen (15) months from the time services are rendered or materials provided. Claims received by VSP after these stated deadlines will be denied unless prohibited by applicable state or federal law. \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 TO OBTAIN FURTHER INFORMATION \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Contact VSP at 80\hich\af43\dbch\af31505\loch\f43 0-877-7195 or }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 www.vsp.com}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 . \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 3\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 EXCLUSIONS AND LIMITATIONS OF BENEFITS \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 This Plan is designed to cover visual needs rather than cosmetic materials. \par \par \hich\af43\dbch\af31505\loch\f43 Some vision care services and/or materials are not covered under this Plan and certain other limitations may apply. Please refer to the EXCLUSIONS AND LIMITATIONS OF BENEFITS section of the attached Schedule of Benefits and/or Additional Benefit Rider (w \hich\af43\dbch\af31505\loch\f43 h\hich\af43\dbch\af31505\loch\f43 en purchased by Client) for details. \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COORDINATION OF BENEFITS \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 \hich\f43 Covered Persons who are covered under two or more insurance plans that include vision care benefits may be eligible for Coordination of Benefits (\'93\loch\f43 \hich\f43 COB\'94\loch\f43 ). VSP will combine other insurance plan \hich\af43\dbch\af31505\loch\f43 s\hich\f43 \rquote \loch\f43 claim payments or reimbursements, if any, with benefits available under Covered Person\hich\f43 \rquote \loch\f43 s VSP Plan, which may reduce or eliminate Covered Person\hich\f43 \rquote \loch\f43 s out-of-pocket expense. Covered Persons covered under more than one VSP Plan may also be able to take advan\hich\af43\dbch\af31505\loch\f43 t\hich\af43\dbch\af31505\loch\f43 age of COB. In order to process claims involving COB, VSP may need to share personal information regarding Covered Persons with other parties (such as another insurance company). When this is necessary, VSP will only share such information with those per \hich\af43\dbch\af31505\loch\f43 s\hich\af43\dbch\af31505\loch\f43 ons or organizations having a legitimate interest in that information and only where such sharing is not prohibited by law. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 URGENT VISION CARE \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Services for conditions of a medical nature are covered by VSP only under specific supplemental eye care Plans p\hich\af43\dbch\af31505\loch\f43 urchased by Client. If Client purchased one of these plans, such coverage will be evidenced in an Additional Benefit Rider. When vision care is necessary for Urgent Conditions, Covered Persons with a supplemental eye care plan may obtain Plan Benefits by \hich\af43\dbch\af31505\loch\f43 c\hich\af43\dbch\af31505\loch\f43 ontacting a VSP Preferred Provider or Open Access Provider. No prior approval from VSP is required for the Covered Person to obtain vision care for Urgent Conditions of a medical nature. If Client has not purchased one of these plans, Covered Persons ar \hich\af43\dbch\af31505\loch\f43 e\hich\af43\dbch\af31505\loch\f43 not covered by VSP for medical services and should contact a physician under Covered Persons\hich\f43 \rquote \loch\f43 medical insurance plan for care. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 HOLD HARMLESS \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Covered Persons shall be held harmless for any sums owed by VSP to the VSP Preferred Provider, other than those sums not covered by the Plan. \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COMPLAINTS AND GRIEVANCES \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Covered Persons have the right to expect quality care from VSP Preferred Providers. \hich\af43\dbch\af31505\loch\f43 \hich\f43 More information is available under \'93\loch\f43 Patient\hich\f43 \rquote \loch\f43 \hich\f43 s Rights and Responsibilities\'94\loch\f43 on VSP\hich\f43 \rquote \loch\f43 s web site at }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 www.vsp.com}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 . Complaints and grievances are disagreements regarding access to care, quality of care, treatment or service. Covered Persons may submit any compl\hich\af43\dbch\af31505\loch\f43 aints and/or grievances, including appeals, in writing to VSP at 3333 Quality Drive, Rancho Cordova, CA 95670-7985 or verbally by calling VSP\hich\f43 \rquote \loch\f43 s Customer Care Division at 1-800-877-7195. VSP will resolve the complaint or grievance within thirty (30) calen\hich\af43\dbch\af31505\loch\f43 d\hich\af43\dbch\af31505\loch\f43 ar days after receipt, unless special circumstances require an extension of time. In that case, resolution shall be achieved as soon as possible, but not later than one hundred twenty (120) calendar days after VSP\hich\f43 \rquote \loch\f43 s receipt of the complaint or grievance. \hich\af43\dbch\af31505\loch\f43 \hich\af43\dbch\af31505\loch\f43 If VSP determines that resolution cannot be achieved within thirty (30) days, VSP will notify the Covered Person of the expected resolution date. Upon final resolution VSP will notify the Covered Person of the outcome in writing. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 4\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 CLAI\hich\af43\dbch\af31505\loch\f43 M PAYMENTS AND DENIALS \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \fi720\li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Initial Determination}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 : VSP will pay or deny claims within thirty (30) calendar days of receipt. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \fi720\li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Claim Denial Appeals}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 : If a claim is denied in whole or in part, under the terms of the Policy, Covered Person or Covered Person\hich\f43 \rquote \hich\af43\dbch\af31505\loch\f43 \hich\f43 s authorized representative may submit a request for a full review of the denial. Covered Person may designate any person, including their provider, as their authorized representative. References in this section to \'93\loch\f43 \hich\f43 Covered Person \'94\loch\f43 include Covered Perso\hich\af43\dbch\af31505\loch\f43 n\loch\af43\dbch\af31505\hich\f43 \rquote \loch\f43 s authorized representative, where applicable. \par }\pard \ltrpar\qj \fi720\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Initial Appeal}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 : The request for review must be made within one hundred eighty (180) calendar days following denial of a claim and should contain sufficient information to identify the claim and the Covere\hich\af43\dbch\af31505\loch\f43 d Person affected by the denial. The Covered Person may review, during normal working hours, any documents held by VSP pertinent to the denial. The Covered Person may also submit written comments or supporting documentation concerning the claim to assis \hich\af43\dbch\af31505\loch\f43 t\hich\af43\dbch\af31505\loch\f43 in VSP\hich\f43 \rquote \loch\f43 s review. VSP\hich\f43 \rquote \loch\f43 s response to the initial appeal, including specific reasons for the decision, shall be provided and communicated to the Covered Person within thirty (30) calendar days after receipt of a request for an appeal from the Covered Person. \hich\af43\dbch\af31505\loch\f43 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \fi720\li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Second Level Appeal}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 : If Covered Person disagrees with the response to the initial appeal of the denied claim, Covered Person has the right to a second level appeal. Within sixty (60) calendar days after receipt of VSP\hich\f43 \rquote \loch\f43 s response to the initial appeal,\hich\af43\dbch\af31505\loch\f43 Covered Person may submit a second appeal to VSP along with any pertinent documentation. VSP shall communicate its final determination to Covered Person in compliance with all applicable state and federal laws and regulations and shall include the spec \hich\af43\dbch\af31505\loch\f43 i\hich\af43\dbch\af31505\loch\f43 fic reasons for the determination. \par }\pard \ltrpar\qj \fi720\li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Other Remedies}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 : When Covered Person has completed the appeals stated herein, additional voluntary alternative dispute resolution options may be available, including mediation. Covered Person may contact the U. S. Depar\hich\af43\dbch\af31505\loch\f43 tment of Labor or the State insurance regulatory agency for details. Additionally, under the provisions of ERISA (Section 502(a) (1) (B) [29 U.S.C. 1132(a) (1) (B)], Covered Person has the right to bring a civil action when all available levels of review \hich\af43\dbch\af31505\loch\f43 s\hich\af43\dbch\af31505\loch\f43 , including the appeal process, have been completed, the claims were not approved in whole or in part, and Covered Person disagrees with the outcome. Covered Persons may also contact the Missouri Department of Insurance, Financial Institutions and Profes \hich\af43\dbch\af31505\loch\f43 s\hich\af43\dbch\af31505\loch\f43 \hich\f43 ional Regulation (\'93\loch\f43 \hich\f43 DIFP\'94\loch\f43 ) at any time by calling toll-free to (800) 726-7390, or by writing to Missouri DIFP, Attn: Consumer Affairs, P.O. Box 690, Jefferson City, MO 65102-0690. \par \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \tab \hich\af43\dbch\af31505\loch\f43 }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Time of Action}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 : No action in law or in equity shall be brought to recove\hich\af43\dbch\af31505\loch\f43 r on the Policy prior to the Covered Person exhausting his/her grievance rights under the Policy and/or prior to the expiration of sixty (60) days after the claim and any applicable documentation have been filed with VSP. No such action shall be brought \hich\af43\dbch\af31505\loch\f43 a\hich\af43\dbch\af31505\loch\f43 fter the expiration of three (3) years from the last date that a claim and any applicable invoices were submitted to VSP, and no such action shall be brought at all unless brought within three (3) years from the expiration of the time within which such ma \hich\af43\dbch\af31505\loch\f43 t\hich\af43\dbch\af31505\loch\f43 erials are required to be submitted in accordance with the terms of the Policy. \par }\pard \ltrpar\ql \li0\ri0\keep\keepn\nowidctlpar\tx360\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs20 \ltrch\fcs0 \f43\fs20\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 INDIVIDUAL CONTINUATION OF BENEFITS \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 In the event this Plan is terminated, VSP coverage may be available for individuals to purchase online }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 www.vsp.com}{ \rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 . Following the death of\hich\af43\dbch\af31505\loch\f43 Enrollee, the surviving spouse and/or Eligible Dependents may also request continuation of coverage under a conversion policy. Covered Persons should contact Enrollee\hich\f43 \rquote \loch\f43 s Plan Administrator for details. \par \par \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT \hich\af43\dbch\af31505\loch\f43 OF 1985 (COBRA) \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that under certain circumstances health plan benefits be made available to eligible participants and their dependents upon the occurrence of a COBRA-qualifying eve \hich\af43\dbch\af31505\loch\f43 nt. If, and only to the extent, COBRA applies to Covered Person\hich\f43 \rquote \loch\f43 s Plan, VSP shall make the statutorily required continuation coverage available for purchase in accordance with COBRA. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 5\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 DEFINITIONS: \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 ADDITIONAL BENEFIT RIDER\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The document, attached as Exhibit C to the Policy (when purchased by Client), which lists selected vision care services and vision care materials which a Covered Person is entitled to receive under the Policy. Additional Benefits are only available when \hich\af43\dbch\af31505\loch\f43 p\hich\af43\dbch\af31505\loch\f43 urchased by Client in conjunction with a Plan Benefit offered under the Schedule of Benefits. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow1\irowband1\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 ASSIGNMENT OF BENEFITS\cell }\pard \ltrpar\qj \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 A written order signed by a Covered Person eighteen (18) years of age or older and included with each claim, directing VSP to pay availa\hich\af43\dbch\af31505\loch\f43 ble Plan Benefits to a named Open Access Provider. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow2\irowband2\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 CLIENT\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 An employer or other entity which contracts with VSP for coverage under the Policy in order to provide vision care coverage to its Enrollees and their Eligible Dependents, if such dependent covera\hich\af43\dbch\af31505\loch\f43 ge is provided. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow3\irowband3\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COORDINATION OF BENEFITS\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Procedure which allows more than one insurance plan to consider Covered Persons\hich\f43 \rquote \loch\f43 vision care claims for payment or reimbursement. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow4\irowband4\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COPAYMENTS\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Those \hich\af43\dbch\af31505\loch\f43 amounts required to be paid by or on behalf of a Covered Person for Plan Benefits which are not fully covered, and which are payable at the time services are rendered or materials ordered. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow5\irowband5\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COVERED PERSON\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 An Enrollee or Eligible Dependent who meets Client\hich\af43\dbch\af31505\loch\f43 's eligibility criteria and on whose behalf premiums have been paid to VSP, and who is covered under the Plan. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow6\irowband6\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 ELIGIBLE DEPENDENT\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Any dependent of an Enrollee who meets the criteria for eligibility established by Client.\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow7\irowband7\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow8\irowband8\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 ENROLLEE\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 An employee or membe\hich\af43\dbch\af31505\loch\f43 r of Client who meets the criteria for eligibility established by Client. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow9\irowband9\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow10\irowband10\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 PLAN OR PLAN BENEFITS\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The vision care services and vision care materials which a Covered Person is entitled to receive by virtue of coverage under the Policy, as defined in the attached Schedule of Benefits and Additional Benefit Rider (when purchased by Client).\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow11\irowband11\ltrrow \ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar \ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow12\irowband12\ltrrow \ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar \ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 OPEN ACCESS PROVIDER\cell }\pard \ltrpar \qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 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. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow13\irowband13\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 PLAN ADMINISTRAT\hich\af43\dbch\af31505\loch\f43 OR\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The person specifically so designated on the Client application, or if an administrator is not so designated, the Client. The Plan Administrator shall have authority to control and manage the operation and administration of the Plan on behalf of the Cli \hich\af43\dbch\af31505\loch\f43 ent. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow14\irowband14\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 POLICY\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The contract between VSP and Client upon which this Plan is based. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow15\irowband15\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 SCHEDULE OF BENEFITS\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The document(s), attached as Exhibit A to the Client Policy maintained by the Plan Administrator and to this Evidence of Coverage, which lists the vision care services and vision care materials which a Covered Person is entitled to receive by virtue of th \hich\af43\dbch\af31505\loch\f43 e\hich\af43\dbch\af31505\loch\f43 Plan. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow16\irowband16\lastrow \ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr \brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 6\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 VSP PREFERRED PROVIDER\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision care materials who has contracted with VSP to Plan Benefits on behalf of Covered Persons of VSP. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 URGENT CARE\cell }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Services for a condition with su\hich\af43\dbch\af31505\loch\f43 dden onset and acute symptoms which requires the Covered Person to obtain immediate medical care, or an unforeseen occurrence requiring immediate, non-medical, action.\cell }\pard \ltrpar \ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow1\irowband1\lastrow \ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2448\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2448\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth7830\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10278\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 7\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 EXHIBIT A \par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 SCHEDULE OF BENEFITS \par \hich\af43\dbch\af31505\loch\f43 \hich\f43 VSP Choice Plan\'ae \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\sa200\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 GENERAL \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 This Schedule of Benefits lists the vision care services and materials to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY("VSP") are entitled, subject to any Copayments and other conditions, limitations and/or exclusions stated herein, and \hich\af43\dbch\af31505\loch\f43 f\hich\af43\dbch\af31505\loch\f43 orms a part of the Policy or Evidence of Coverage to which it is attached. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\sl-240\slmult0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 VSP Preferred Providers are those doctors that have agreed to participate in VSP\hich\f43 \rquote \loch\f43 s Choice Network. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\sa200\sl-200\slmult0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 BENEFIT PERIOD \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 A twelve-month period beginning on January 1st and ending on December 31st. \par \par }\pard \ltrpar\qj \li0\ri0\sa156\sl-200\slmult0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 ELIGIBILITY \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The following are Covered Persons under this Plan, pursuant to eligibility criteria established by Client: \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \fi-360\li360\ri0\widctlpar\tx360\wrapdefault\faauto\rin0\lin360\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \hich\af43\dbch\af31505\loch\f43 Enrollee \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Legal Spouse of Enrollee \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Any child of Enroll\hich\af43\dbch\af31505\loch\f43 ee, including natural child from the date of birth, legally adopted child from the date of placement for adoption with the Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Dependent children are covered up\hich\af43\dbch\af31505\loch\f43 to the end of the month in which they turn age 26. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self-sustaining employment because of mental or physical disability, and chiefly\hich\af43\dbch\af31505\loch\f43 dependent upon Enrollee for support and maintenance. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 PLAN BENEFITS \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 VSP PREFERRED PROVIDERS \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COPAYMENT \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses, frames or Necessary Contact Lenses) are provided, there shall be an additional $10.00 Copayment payable at the \hich\af43\dbch\af31505\loch\f43 t\hich\af43\dbch\af31505\loch\f43 ime the materials are ordered. The Copayment shall not apply to Elective Contact Lenses. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 8\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COVERED SERVICES AND MATERIALS \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 EYE EXAMINATION- Covered in full* once every 12 months** \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Comprehensive examination of visual functions and prescr \hich\af43\dbch\af31505\loch\f43 iption of corrective eyewear. \par }\pard \ltrpar\qj \li0\ri0\sa200\sl-200\slmult0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 LENSES - Covered in full* once every 12 months** \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Spectacle}{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Lenses (Single, Lined Bifocal, Lined Trifocal or Lenticular) \par \par \hich\af43\dbch\af31505\loch\f43 Polycarbonate lenses are covered in full for dependent children up to}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid1975095 \hich\af43\dbch\af31505\loch\f43 the end of the month in which they turn}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 age 26 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Standa\hich\af43\dbch\af31505\loch\f43 rd Progressive Lenses covered in full \par \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 FRAMES -}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Covered up to the Plan allowance* once every 24 months** \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The VSP Preferred Provider will prescribe and order Covered Person\hich\f43 \rquote \loch\f43 s lenses, verify the accuracy of finished lenses, and assist Covered Person with f\hich\af43\dbch\af31505\loch\f43 rame selection and adjustment. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 CONTACT LENSES \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 ELECTIVE \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Elective Contact Lenses are covered up to $150.00 once every 12 months** \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 The Elective Contact Lens allowance applies to both the doctor's fitting and evaluation fees, and to materials. \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 NECESSARY \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Necessary Contact Lenses are covered in full* once every 12 months** \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's VSP Preferred Provider. \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 Contact Lenses are provided in place of spectacle lens and frame benefits available herein. \par \par \hich\af43\dbch\af31505\loch\f43 *Less any applicable Copayment. \par \hich\af43\dbch\af31505\loch\f43 ** beginning with the first day of the Benefit Period. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 9\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 LOW VISION \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 Professional services for severe visual prob\hich\af43\dbch\af31505\loch\f43 lems not correctable with regular lenses, including: \par \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Supplemental Testing: Covered in full*. \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \tab }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 -Includes evaluation, diagnosis and prescription of vision aids where indicated. \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Supplemental Aids: 75% of VSP Preferred Provider\hich\f43 \rquote \loch\f43 s fee, up to $1000.00* \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 *Maximum benefit for all Low Vision services and materials is $1000.00 every two (2) years and a maximum of two supplemental tests within a two-year period. \par \par \hich\af43\dbch\af31505\loch\f43 Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when presc\hich\af43\dbch\af31505\loch\f43 ribed by Covered Person's VSP Preferred Provider. \par }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 10\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\qj \li0\ri0\sa200\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 EXCLUSIONS AND LIMITATIONS OF BENEFITS \par }\pard \ltrpar\ql \li0\ri0\widctlpar\tx360\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons ma\hich\af43\dbch\af31505\loch\f43 y obtain details regarding frame brand availability from their VSP Member Doctor or by calling VSP\hich\f43 \rquote \loch\f43 s Customer Care Division at (800) 877-7195. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 NOT COVERED \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \fi-360\li360\ri0\keepn\nowidctlpar\tx360\tqr\tx10080\wrapdefault\faauto\rin0\lin360\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \hich\af43\dbch\af31505\loch\f43 Services and/or materials not specifically included in this Schedule as covered Plan Benefits. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 \hich\f43 Plano lenses (lenses with refractive correction of less than \'b1\loch\f43 .50 diopter), except as specifically allowed under the Suncare enhancement, if purchased by Client. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Two pair of glasses instead of bifocals. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Replacement of lenses, frames and/or contact le\hich\af43\dbch\af31505\loch\f43 nses furnished under this Plan which are lost or damaged, except at the normal intervals when Plan Benefits are otherwise available. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Orthoptics or vision training and any associated supplemental testing. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Medical or surgical treatment of the eyes. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Ref\hich\af43\dbch\af31505\loch\f43 itting of contact lenses after the initial (90-day) fitting period. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Contact lens modification, polishing or cleaning. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Local, state and/or federal taxes, except where VSP is required by law to pay. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 11\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 REIMBURSEMENT SCHEDULE \par }\pard \ltrpar\ql \li0\ri0\keep\keepn\nowidctlpar\tx720\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 OPEN ACCESS\hich\af43\dbch\af31505\loch\f43 PROVIDERS \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\tx720\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COPAYMENT \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses, frames or Necessary Contact Lenses) are provided, there shall be an additional $10.00 Copayment payable at the \hich\af43\dbch\af31505\loch\f43 t\hich\af43\dbch\af31505\loch\f43 ime the materials are ordered. The Copayment shall not apply to Elective Contact Lenses. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COVERED SERVICES AND MATERIALS \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 EYE EXAMINATION: }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Up to $ 45.00* once every 12 months**}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Comprehensive examination of visual functions and prescription of corrective \hich\af43\dbch\af31505\loch\f43 eyewear. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\sa120\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 SPECTACLE LENSES \par }\pard \ltrpar\ql \li0\ri0\sa120\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Single Vision Up to $ 30.00* once every 12 months** \par \hich\af43\dbch\af31505\loch\f43 Bifocal Up to $ 50.00* once every 12 months** \par \hich\af43\dbch\af31505\loch\f43 Trifocal Up to $ 65.00* once every 12 months** \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Lenticular Up to $100.00* once every 12 months** \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 FRAMES: Covered up to $ 70.00* once every 24 months** \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 CONTACT LENSES \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 ELECTIVE \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Elective Contact Lenses are covered up to $105.00 once every 12 months** \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 The Elective Contact Lens allowance applies to both the doctor's fitting and evaluation fees, and to materials. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 NECESSARY \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Necessary Contact Lenses are covered up to $210.00* once every 12 months** \par \par \hich\af43\dbch\af31505\loch\f43 Necessary Contact Lenses are a Plan Benefit when specific\hich\af43\dbch\af31505\loch\f43 benefit criteria are satisfied and when prescribed by Covered Person's Doctor. \par \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Contact Lenses are provided in place of spectacle lens and frame benefits available herein. \par \par \hich\af43\dbch\af31505\loch\f43 *Less any applicable Copayment. \par \hich\af43\dbch\af31505\loch\f43 **beginning with the first day of the Benefit Peri\hich\af43\dbch\af31505\loch\f43 od. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 12\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 LOW VISION \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 Professional services for severe visual problems not correctable with regular lenses, including: \par \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Supplemental Testing: Up to $125.00*. \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8529593 \tab }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 -Includes evaluation, diagnosis and prescription of vision aids where indicated. \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Supplemental Aids: 75% of VSP Preferred Provider\hich\f43 \rquote \loch\f43 s fee, up to $1000.00* \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 *Maximum benefit for all Low Vision services and materials is $1000.00 every two (2) years and a maxi\hich\af43\dbch\af31505\loch\f43 mum of two supplemental tests within a two-year period. \par \par \hich\af43\dbch\af31505\loch\f43 Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's VSP Preferred Provider. \par \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 OPEN ACCESS PROVIDERS \par }\pard \ltrpar\qj \fi-360\li360\ri0\keepn\nowidctlpar\tx360\tqr\tx10080\wrapdefault\faauto\rin0\lin360\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \hich\af43\dbch\af31505\loch\f43 Exclusions and limitations \hich\af43\dbch\af31505\loch\f43 of benefits described above for VSP Preferred Providers shall also apply to services rendered by Open Access Providers. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Services from an Open Access Provider are in lieu of services from a VSP Preferred Provider. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 There is no guarantee that the amount \hich\af43\dbch\af31505\loch\f43 reimbursed will be sufficient to pay the cost of services or materials in full. \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 VSP is unable to require Open Access Providers to adhere to VSP\hich\f43 \rquote \loch\f43 s quality standards. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 13\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Exhibit C \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 VISION SERVICE PLAN INSURANCE COMPANY \par \hich\af43\dbch\af31505\loch\f43 ADDITIONAL BENEFIT RIDER \par }\pard \ltrpar\qc \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 DIABETIC EYECARE PLUS PROGRAM \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 GENERAL \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 This Rider lists additional vision care b\hich\af43\dbch\af31505\loch\f43 enefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY ("VSP") are entitled, subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein or in the Schedule of Benefits with which it is associat \hich\af43\dbch\af31505\loch\f43 e\hich\af43\dbch\af31505\loch\f43 d. Plan Benefits under the Diabetic Eyecare Plus Program are available to Covered Persons who have been diagnosed with type 1 or type 2 diabetes and specific ophthalmological conditions. This Rider forms a part of the Policy or Evidence of Coverage to whi \hich\af43\dbch\af31505\loch\f43 c\hich\af43\dbch\af31505\loch\f43 h it is attached. \par \par }\pard \ltrpar\qj \li0\ri0\sa156\sl-200\slmult0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 ELIGIBILITY \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The following are Covered Persons under this Policy, pursuant to eligibility criteria established by Client: \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \fi-360\li360\ri0\widctlpar\tx360\wrapdefault\faauto\rin0\lin360\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \hich\af43\dbch\af31505\loch\f43 Enrollee \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Legal Spouse of Enrollee \par \bullet \tab \hich\af43\dbch\af31505\loch\f43 Any child of Enrollee, including natural child from the date of birth, lega\hich\af43\dbch\af31505\loch\f43 lly adopted child from the date of placement for adoption with the Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Dependent children are covered up to the end of the month in which they turn age 26. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 A d\hich\af43\dbch\af31505\loch\f43 ependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self-sustaining employment because of mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance. \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 PROGRAM DESCRIPTION \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 \hich\f43 The Diabetic Eyecare Program (\'93\loch\f43 \hich\f43 DEP\'94\loch\f43 ) is intended to be a supplement to Covered Person\hich\f43 \rquote \loch\f43 s group medical plan. Providers will first submit a claim to Covered Person\hich\f43 \rquote \loch\f43 s group medical insurance plan, and then to VSP. Any amounts not paid b\hich\af43\dbch\af31505\loch\f43 \hich\f43 y the medical plan will be considered for payment by VSP. (This is referred to as \'93\loch\f43 \hich\f43 Coordination of Benefits\'94\loch\f43 \hich\f43 or \'93\loch\f43 COB." Please refer to the Coordination of Benefits section of Covered Person \hich\f43 \rquote \loch\f43 s Evidence of Coverage for additional information regarding COB.\hich\af43\dbch\af31505\loch\f43 )\hich\af43\dbch\af31505\loch\f43 If Covered Person does not have a group medical plan, providers will submit claims directly to VSP. \par \par \hich\af43\dbch\af31505\loch\f43 Examples of symptoms which may result in an Covered Person seeking services under DEP Plus may include, but are not limited to: \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8529593 \par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4680\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4788\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9468\pard \ltrpar\qj \fi-360\li360\ri0\keepn\nowidctlpar\intbl\tx360\tx1260\wrapdefault\faauto\rin0\lin360 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \hich\af43\dbch\af31505\loch\f43 blurry vision\cell \bullet \tab \hich\af43\dbch\af31505\loch\f43 troubl\hich\af43\dbch\af31505\loch\f43 e focusing\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4680\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4788\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9468\row \ltrrow}\pard \ltrpar\qj \fi-360\li360\ri0\keepn\nowidctlpar\intbl\tx360\wrapdefault\faauto\rin0\lin360 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \hich\af43\dbch\af31505\loch\f43 transient loss of vision\cell }\pard \ltrpar\qj \fi-360\li360\ri0\keepn\nowidctlpar\intbl\tx360\tx1260\wrapdefault\faauto\rin0\lin360 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \loch\af43\dbch\af31505\hich\f43 \'93\loch\f43 \hich\f43 floating\'94\loch\f43 spots\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow1\irowband1\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4680\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4788\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9468\row \ltrrow}\pard \ltrpar\qj \fi-360\li360\ri0\keepn\nowidctlpar\intbl\tx360\tx1260\wrapdefault\faauto\rin0\lin360 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \hich\af43\dbch\af31505\loch\f43 tunnel vision\cell \bullet \tab \hich\af43\dbch\af31505\loch\f43 visual distortion\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow2\irowband2\lastrow \ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4680\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4788\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9468\row }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Examples of conditions which may require management under DEP Plus may include, but are not limited to: \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \ltrrow}\pard \ltrpar\qj \fi-360\li360\ri0\keepn\nowidctlpar\intbl\tx360\tx1260\wrapdefault\faauto\rin0\lin360 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \hich\af43\dbch\af31505\loch\f43 diabetic retinopathy\cell \bullet \tab \hich\af43\dbch\af31505\loch\f43 age-related macular degeneration\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4680\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4788\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9468\row \ltrrow}\pard \ltrpar\qj \fi-360\li360\ri0\keepn\nowidctlpar\intbl\tx360\tx1260\wrapdefault\faauto\rin0\lin360 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \hich\af43\dbch\af31505\loch\f43 rubeosis\cell \bullet \tab \hich\af43\dbch\af31505\loch\f43 glaucoma\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow1\irowband1\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4680\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4788\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9468\row \ltrrow}\pard \ltrpar\qj \fi-360\li360\ri0\keepn\nowidctlpar\intbl\tx360\wrapdefault\faauto\rin0\lin360 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \bullet \tab \hich\af43\dbch\af31505\loch\f43 diabetic macular edema\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\tx1260\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow2\irowband2\lastrow \ltrrow \ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4680\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx4680 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4788\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9468\row }\pard \ltrpar \ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 14\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\ql \li0\ri0\keepn\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\keep\keepn\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 PROCEDURES FOR OBTAINING DIABETIC EYECARE PLUS SERVICES \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COVERED PERSON HAS A GROUP MEDICAL PLAN \par \par \hich\af43\dbch\af31505\loch\f43 The DEP Plus Program provides coverage fo\hich\af43\dbch\af31505\loch\f43 r certain vision-related medical services as a supplement to Covered Person\hich\f43 \rquote \loch\f43 s group medical plan. Covered Persons should refer to the plan booklet, certificate of coverage or other benefits description for their group medical plan to determine how to obt\hich\af43\dbch\af31505\loch\f43 a\hich\af43\dbch\af31505\loch\f43 in plan benefits. \par \par \hich\af43\dbch\af31505\loch\f43 The provider should first submit a claim to Covered Person\hich\f43 \rquote \loch\f43 \hich\f43 s group medical insurance plan. Any amounts not paid by the medical plan may then be considered for payment by VSP. (This is referred to as \'93\loch\f43 \hich\f43 Coordination of Benefits\'94\loch\f43 \hich\f43 or \'93\loch\f43 COB." \hich\af43\dbch\af31505\loch\f43 Please refer to the Coordination of Benefits section of Covered Person\hich\f43 \rquote \loch\f43 s Evidence of Coverage for additional information regarding COB.) \par \par \hich\af43\dbch\af31505\loch\f43 COVERED PERSON DOES NOT HAVE A GROUP MEDICAL PLAN \par \par \hich\af43\dbch\af31505\loch\f43 When Covered Person does not have a group medical plan, the DEP Pl\hich\af43\dbch\af31505\loch\f43 us Program provides Plan Benefits as follows: \par \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\tx720\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 1. Covered Person contacts a VSP Network Doctor and makes an appointment. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\tx720\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 2. Covered Person pays the applicable Copayment at the time of each DEP Plus Program visit and amounts for any additional services not covered by the Plan. \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 REFERRALS \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \hich\af43\dbch\af31505\loch\f43 If Covered Person's Member Doctor cannot provide Covered Services, the doctor will refe\hich\af43\dbch\af31505\loch\f43 r the Covered Person to another Member Doctor or to a physician whose offices provide the necessary services. \par \par \hich\af43\dbch\af31505\loch\f43 If the Covered Person requires services beyond the scope of DEP Plus, the Member Doctor will refer the Insured to a physician. \par \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Referrals are int\hich\af43\dbch\af31505\loch\f43 ended to insure that Covered Persons receive the appropriate level of care for their presenting condition. }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Covered Persons do not require a referral from a Member Doctor in order to obtain Plan Benefits. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 15\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\qj \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 PLAN BENEFITS \par \hich\af43\dbch\af31505\loch\f43 VSP PREFERRED PROVIDER \par }\pard \ltrpar\ql \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COVERED SERVICES \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Eye Examination:}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Covered in full after a Copayment of $20.00. \par \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Special Ophthalmological Services:}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Covered in Full. \par \par }\pard \ltrpar\ql \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 EXCLUSIONS AND LIMITATIONS OF BENEFITS \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The Diabetic Eyecare Plus Program provides coverage for limited, vision-related medical services. A current list of these procedures will be made available to Covered Persons upon request. The frequency at which these services may be provided is depende \hich\af43\dbch\af31505\loch\f43 n\hich\af43\dbch\af31505\loch\f43 t upon the specific service and the diagnosis associated with such service. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 NOT COVERED \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \fi-360\li360\ri0\nowidctlpar\tx360\tx1260\tqr\tx10080\wrapdefault\faauto\rin0\lin360\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 1.\tab Services and/or materials not specifically included in this Rider as covered Plan Benefits. \par \hich\af43\dbch\af31505\loch\f43 2.\tab Frames, spectacle lenses, contact lenses or any other ophthalmic mat\hich\af43\dbch\af31505\loch\f43 erials. \par \hich\af43\dbch\af31505\loch\f43 3.\tab Orthoptics or vision training and any associated supplemental testing. \par \hich\af43\dbch\af31505\loch\f43 4.\tab Surgery of any type, and any pre- or post-operative services and/or supplies. \par \hich\af43\dbch\af31505\loch\f43 5.\tab Treatment for any pathological conditions. \par \hich\af43\dbch\af31505\loch\f43 6.\tab An eye exam required as a condition of emplo\hich\af43\dbch\af31505\loch\f43 yment. \par \hich\af43\dbch\af31505\loch\f43 7.\tab Insulin or any medications or supplies of any type. \par \hich\af43\dbch\af31505\loch\f43 8.\tab Local, state and/or federal taxes, except where VSP is required by law to pay. \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 16\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\ql \li0\ri0\keepn\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 DIABETIC EYECARE PLUS PROGRAM DEFINITIONS \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2313\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2313\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8055\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10368\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 AMD\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 \hich\f43 Age-related macular degeneration (AMD) is a disease that destroys the clear, \'93\loch\f43 \hich\f43 straight ahead\'94\loch\f43 central vision necessary for reading, driving, identifying faces and performing other daily tasks. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2313\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2313\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8055\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10368\row \ltrrow}\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Diabetes\cell \hich\af43\dbch\af31505\loch\f43 A disease where the pancreas has a problem either making, or making and using, insulin. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow1\irowband1\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2313\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2313\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8055\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10368\row \ltrrow}\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Type 1 Diabetes\cell \hich\af43\dbch\af31505\loch\f43 A disease in which the pancreas stops making insulin. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow2\irowband2\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2313\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2313\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8055\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10368\row \ltrrow}\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Type 2 Diabetes\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 A disease in which the pancreas either makes too little insulin or cannot prop\hich\af43\dbch\af31505\loch\f43 erly use the insulin it makes to convert blood glucose to energy. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow3\irowband3\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2313\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2313\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8055\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10368\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Diabetic Retinopathy \par }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\qj \li0\ri0\keepn\nowidctlpar\intbl\tx1260\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 A weakening in the small blood vessels at the back of the eye. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow4\irowband4\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2313\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2313\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8055\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10368\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Rubeosis\cell }\pard \ltrpar\qj \li0\ri0\keepn\nowidctlpar\intbl\tx1260\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Abnormal blood vessel growth on the iris and the structures in the front of the eye. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow5\irowband5\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2313\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2313\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8055\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10368\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Diabetic Macular Edema\cell \hich\af43\dbch\af31505\loch\f43 Swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the macula. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow6\irowband6\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2313\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2313\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8055\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10368\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Glaucoma\cell \hich\af43\dbch\af31505\loch\f43 A disease in which damage to the optic nerve leads to progressive, irreversible vision loss. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow7\irowband7\ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2313\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2313\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8055\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10368\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Special \line Ophthalmolog\hich\af43\dbch\af31505\loch\f43 ical Services\cell }\pard \ltrpar\ql \li0\ri0\keepn\nowidctlpar\intbl\tx1260\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Medical eyecare procedures for the investigation and management of ocular disorders associated with diabetic eye disease, glaucoma and/or AMD. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow8\irowband8\lastrow \ltrrow\ts11\trleft0\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2313\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx2313\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8055\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10368\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \ltrrow\trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\intbl\pvpg\phpg\posx720\posy15300\dxfrtext1\dfrmtxtx1\dfrmtxty72\wraparound\faauto\rin0\lin0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 17\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trrh360\trleft0\tpvpg\tphpg\tposx720\tposy15300\tdfrmtxtLeft1\tdfrmtxtRight1\tdfrmtxtTop72\tdfrmtxtBottom72\trftsWidth1\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx10800\row }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 PLAN BENEFITS \par }\pard \ltrpar\ql \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 OPEN ACCESS PROVIDERS \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\tx360\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 A Non-Member Provider may require Covered Person to pay for all services in full at the time of the visit. If so, Covered Person should then submit a claim to VSP for reimbursement. \par }\pard \ltrpar\ql \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 COVERED SERVICES \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Eye Examination:}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Covered up to $ 100.00 after a $20.0\hich\af43\dbch\af31505\loch\f43 0 Copayment. \par }\pard \ltrpar\qj \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Special Ophthalmological Services:}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Covered up to $120.00 per individual service. \par }\pard \ltrpar\ql \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 EXCLUSIONS AND LIMITATIONS OF BENEFITS \par }\pard \ltrpar\qj \li0\ri0\keep\keepn\nowidctlpar\tx1260\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \fi-360\li360\ri0\widctlpar\tx360\wrapdefault\faauto\rin0\lin360\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 1.\tab Exclusions and limitations of benefits described above for Member Doctors shall also apply to services rendered by N\hich\af43\dbch\af31505\loch\f43 on-Member Providers. \par \hich\af43\dbch\af31505\loch\f43 2.\tab Services from a Non-Member Provider are in lieu of services from a Member Doctor. \par \hich\af43\dbch\af31505\loch\f43 3.\tab There is no guarantee that the amount reimbursed will be sufficient to pay the cost of services or materials in full. \par \hich\af43\dbch\af31505\loch\f43 4.\tab VSP is unable to require Non-Member Providers to adhere to VSPs quality standards. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \sect }\sectd \ltrsect\linex0\sectdefaultcl\sftnbj \pard\plain \ltrpar \qc \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\ul\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Summary of Benefits and Coverage \par }\pard \ltrpar\qc \li0\ri0\sl288\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 VSP Choice Plan \par }\pard \ltrpar\ql \li0\ri0\sl360\slmult0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par }\pard \ltrpar\ql \li0\ri0\sl288\slmult0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Prepared for: \tab \tab 91ÖÆƬ³§ \par }\pard \ltrpar\ql \li0\ri0\sl288\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Group ID: \tab \tab 30051106 \par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Effective Date:\tab \tab JANUARY 1, 2019 \par }\pard \ltrpar\ql \li0\ri0\sb144\sl244\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The \hich\af43\dbch\af31505\loch\f43 Affordable Care Act requires that health insurance companies and group health plans provide consumers with a simple and consistent benefit and coverage information document, beginning September 23, 2012.\~ This document is a Summary of Benefits and Coverage\hich\af43\dbch\af31505\loch\f43 \hich\af43\dbch\af31505\loch\f43 (SBC). \par }\pard \ltrpar\ql \li0\ri0\sb72\sl244\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 The grid below is being provided for your convenience and mirrors the sample SBC that the U.S. Department of Labor has published. All the information provided is relative to your plan and described in detail in the preceding Evidence of Coverage. \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trrh360\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth4096\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336\clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1772\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\pard \ltrpar\qc \li0\ri0\sl360\slmult0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Common\cell \hich\af43\dbch\af31505\loch\f43 Services You\cell \hich\af43\dbch\af31505\loch\f43 Your cost if you use an\cell \hich\af43\dbch\af31505\loch\f43 Limitations and\cell }\pard \ltrpar \ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow0\irowband0\ltrrow\ts11\trrh360\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440 \clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240 \clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth4096\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336 \clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1772\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trrh380\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1980\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx5220\clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 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\ts11\trrh380\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1980\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx5220\clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2115\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1772\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts11\trrh405\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1980\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx5220\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2116\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1772\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\pard \ltrpar\qc \li0\ri0\sl360\slmult0 \widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Event\cell }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }{\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Provider\cell \hich\af43\dbch\af31505\loch\f43 Provider\cell }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow2\irowband2\ltrrow\ts11\trrh405\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1980\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx5220\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2116\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1772\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\row \ltrrow}\trowd \irow3\irowband3\ltrrow \ts11\trrh1460\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1980\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx5220\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2115\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1773\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\pard \ltrpar\ql \li0\ri0\sl360\slmult0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 If you or your dependents (if applicable) need eyecare\cell \hich\af43\dbch\af31505\loch\f43 Eye Exam\cell \hich\af43\dbch\af31505\loch\f43 $10.00 Copay \par }\pard \ltrpar\ql \li0\ri0\sl360\slmult0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\cf19\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Reimbursed up to \par \hich\af43\dbch\af31505\loch\f43 $45.00\cell \hich\af43\dbch\af31505\loch\f43 Exam covered in full every 12 months**\cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow3\irowband3\ltrrow\ts11\trrh1460\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1980\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx5220\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2115\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1773\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\row \ltrrow}\trowd \irow4\irowband4\ltrrow\ts11\trrh5420\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1980\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx5220\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2115\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1773\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\pard \ltrpar \ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sl360\slmult0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\cf1\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Frames, Lenses or \par }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Contacts\cell }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\cf19\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Glasses: $10.00 Copay (lenses \line and/or frames only); \par }\pard \ltrpar\ql \li0\ri0\sl360\slmult0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\cf19\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Frames reimbursed up to $ 70.00 \par \hich\af43\dbch\af31505\loch\f43 SV Lenses reimbursed up to $ 30.00 \par \hich\af43\dbch\af31505\loch\f43 Bi-Focal Lenses reimbursed up to \par \hich\af43\dbch\af31505\loch\f43 $ 50.00 \par \hich\af43\dbch\af31505\loch\f43 Tri-Focal Lenses reimbursed up to\line $ 65.00 \par \hich\af43\dbch\af31505\loch\f43 Lenticular Lenses reimbursed up to\line $100.00 \par \hich\af43\dbch\af31505\loch\f43 ECL reimbursed up to $105.00\cell \hich\af43\dbch\af31505\loch\f43 Frames covered every 24 months** \par \hich\af43\dbch\af31505\loch\f43 Lenses covered every 12 months** \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow4\irowband4\ltrrow\ts11\trrh5420\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1980\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx5220\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2115\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1773\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\row \ltrrow}\trowd \irow5\irowband5\ltrrow\ts11\trrh380\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1980\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx5220\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2116\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336\clvertalt\clbrdrt\brdrnone \clbrdrl \brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1772\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\pard \ltrpar \ql \li0\ri0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sl360\slmult0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\cf1\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Fees\cell }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \cell \cell }\pard \ltrpar\ql \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow5\irowband5\ltrrow \ts11\trrh380\trleft0\trftsWidth1\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1440\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx1440\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1800\clpadl0\clpadt72\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx3240\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1980\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx5220\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth2116\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx7336\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20\brdrcf1 \clbrdrb\brdrs\brdrw20\brdrcf1 \clbrdrr\brdrs\brdrw20\brdrcf1 \cltxlrtb\clftsWidth3\clwWidth1772\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx9109\row \ltrrow}\trowd \irow6\irowband6\lastrow \ltrrow \ts11\trrh635\trleft0\trftsWidth1\trftsWidthA3\trwWidthA252\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8856\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx8856\pard \ltrpar\ql \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af43\afs20 \ltrch\fcs0 \f43\fs20\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 ** }{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Beginning with the first day of the Benefit Period. \par }\pard \ltrpar\ql \li0\ri0\sl360\slmult0\widctlpar\intbl\wrapdefault\faauto\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \cell }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1 \widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid8529593 \trowd \irow6\irowband6\lastrow \ltrrow\ts11\trrh635\trleft0\trftsWidth1\trftsWidthA3\trwWidthA252\tblind10\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw20\brdrcf1 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth8856\clpadl0\clpadt0\clpadb0\clpadr0\clpadfl3\clpadft3\clpadfb3\clpadfr3\clshdrawnil \cellx8856\row }\pard \ltrpar \ql \li0\ri0\sb42\sl360\slmult0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af43\afs24 \ltrch\fcs0 \b\f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 Your Grievance and Appeals Rights: \par }\pard \ltrpar\ql \li0\ri0\sl244\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 \f43\fs24\insrsid8529593 \hich\af43\dbch\af31505\loch\f43 If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. 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