6-Attachment E SoBC Vision.pdf

Attachment E

Summary of Benefits and Coverage - Vision

Summary of

Additional discounts

Take a sneak peek before enrolling

20%

20%

40%

OFF

OFF

OFF

Complete pair of prescription eyeglasses

Non-prescription sunglasses

Remaining balance beyond plan coverage are for in-network providers only.

Vision Care Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148.

PLAN 5: 12/12/24/$150 MS 600 V

Frequency Examination Once every 12 months Lenses or contact lenses Once every 12 months Frame Once every 24 months

N/A

Vision Care Services

Exam with dilation as necessary $10 copay Up to $30 Retinal Imaging $39 N/A

N/A

Frames Any available frame at provider location Up to $75

Single vision $10 copay Up to $25 Bifocal $10 copay Up to $40 Trifocal $10 copay Up to $55 Lenticular $10 copay Up to $55 Standard progressive lens $75 copay Up to $40 Premium progressive lens See table on page 2. Up to $40

Tint (solid and gradient) $15 N/A

Scratch resistant coating $0 Up to $5

Polycarbonate lenses $0 kids; $40 adults Up to $5 kids

Ultraviolet coating $15 N/A

See table on page 2. N/A

High index lenses N/A

Polarized lenses N/A

Photocromatic/transitions plastic $75 N/A

Conventional Up to $120 Disposable $0 copay, $150 allowance, plus balance over $150 Up to $120 Medically necessary $0 copay, paid-in-full Up to $210

Laser vision correction N/A

N/A

Amplifon hearing discount guarantee on discounted hearing aids N/A

Additional discounts N/A

Employee $8.08 Employee + spouse $15.36 Employee + child(ren) $16.15 Employee + family $23.76

Dependent coverage is available to age 26.

• For a complete list of in-network providers near you, visit member.eyemedvisioncare.com/ bcbstx or call 1.855.556.8796.

• For LASIK providers, call 1.877.5LASER6.

City of Leander

Standard progressive $75 copay

Premium progressives3 as follows:

Tier 1 $95 copay

Tier 2 $105 copay

Tier 3 $120 copay

Tier 4 $75 copay, 80% of charge less $120 allowance

$45

3 coatings as follows:

Tier 1 $57

Tier 2 $68

Tier 3 80% of charge

Photochromic $75

Polarized 80% of charge

1. Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; aniseikonic lenses

2). Medical and/or surgical treatment of the eye, eyes or supporting structures

3. Any eye or vision examination, or any corrective eyewear required by a Policyholder as a condition of employment; safety eyewear

4. Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof

5. Plano (non-prescription) lenses and/or contact lenses

6. Non-prescription sunglasses

7. Two pair of glasses in lieu of bifocals

8. Services rendered after the date an insured person ceases to be covered under the policy, except when vision materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order providing vision care

10. Lost or broken lenses, frames, glasses or contact lenses will not be would next become available

750936.1223

1Member Reimbursement Out-of-Network will be the lesser of the listed amount or the member’s actual cost from the out-of-network provider. In certain states, members may be required to pay the full retail rate. 2 the listed product level. All providers are not required to carry all brands at all levels. 3

For employee use. This piece is for illustrative purposes only and is not a contract. It is intended to provide only a brief summary of the type of policy and insurance coverage advertised. The policy provides the actual terms of coverage, including any exclusions, conditions and limitations to coverage.

Insurance Company.

Vision Insurance offered by Dearborn Life Insurance Company located at 701 E. 22nd Street, Lombard, IL 60148. Blue Cross and Blue Shield of Texas, is the trade name of Dearborn Life Insurance Company, an Independent Licensee of the Blue Cross and Blue Shield Association. EyeMed Vision Care, LLC and First American Administrators, Inc. are independent companies that offer provider network and administration services.

10/24/2025

Voluntary Vision Insurance

Employee Benefit Booklet

City of Leander

VF030219-0001

Class 1-01

Plan 5 - 12.12.24 $150

DL10-VIC-0119 TX

DEARBORN LIFE INSURANCE COMPANY

(A stock life insurance company, herein called “We” “Us” or “Our”)

Administrative Office Address: 701 E. 22nd Street, Lombard IL 60148

Having issued Group Policy No. VF030219

(herein called the Policy) to

City of Leander (herein called the Policyholder)

GROUP VISION INSURANCE CERTIFICATE

CERTIFIES that You are insured, if You qualify under the ELIGIBILITY AND EFFECTIVE DATES provision, and remain insured in accordance with the terms of the Policy. Your insurance is subject to all the definitions, exclusions, limitations and conditions of the Policy, and it takes effect as stated in the ELIGIBILITY AND EFFECTIVE DATES provision.

This Certificate describes Your eligibility for benefits and the terms and provisions of the Policy. It replaces and cancels any other Certificate previously issued to You under the Policy.

If the terms and provisions of this Group Insurance Certificate (issued to You) are different from the Policy (issued to the Policyholder), the Policy will govern. Your coverage may be canceled or changed in whole or in part under the terms and provisions of the Policy

READ THIS CERTIFICATE CAREFULLY

Signed for Dearborn Life Insurance Company

Secretary President

Voluntary Group Vision Insurance Certificate with Dependent Vision Benefits

Non-Participating

THIS IS A LIMITED BENEFIT POLICY

THIS IS NOT A WORKERS' COMPENSATION POLICY

THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY

OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER

TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’

COMPENSATION SYSTEM.

DL10-VIC-0119 TX

TABLE OF CONTENTS

Schedule of Benefits

Eligibility and Effective Date Provisions

Vision Insurance Benefits

Limitations and Exclusions

Termination Provisions

General Provisions

Uniform Claim Provisions

General Definitions

Continuation of Coverage Rights under COBRA Notice

DL10-VIC-0119 TX 1

SCHEDULE OF BENEFITS

POLICYHOLDER: City of Leander

POLICY NUMBER: VF030219

POLICY EFFECTIVE DATE: 01/01/2026

ANNUAL ENROLLMENT PERIOD: October 15 to November 15

ELIGIBILITY:

Class 01

All active full-time Employees of the Policyholder working in the United States of America who are Actively at Work for the Policyholder and who have completed the Eligibility Waiting Period are eligible for the insurance. A full-time Employee is one who regularly works a minimum of 30 hours per week for the Policyholder. Part-time, seasonal and temporary Employees of the Policyholder are not eligible.

Eligibility Waiting Period: Current Employees: First of the month following or coinciding with 0 Days of continuous, full-time Active Work New Employees: First of the month following or coinciding with 0 Days of continuous, full-time Active Work

Policyholder Contribution: Voluntary Vision 0% of premium

Coverage For: Employee, Spouse, and Dependent Child

Dependent Benefit amounts unless otherwise stated:

Spouse Benefits 100% of the Employee's benefit amount Dependent Child Benefits Live birth to age 26

100% of the Employee's benefit amount

Insured Persons have the right to obtain vision care from the Provider of his or her choice. However, payment of benefits varies depending on the type of Provider chosen. Benefits are payable as shown in the following Schedule of Benefits:

BENEFIT EyeMed Provider Non-Contracting Provider

Vision Examination* Insured 12 months

$10 Co-payment up to $30

VISION MATERIALS

Standard Plastic Lenses Insured 12 months

Single Vision $10 Co-payment up to $25

Bifocal $10 Co-payment up to $40

Trifocal $10 Co-payment up to $55

Lenticular $10 Co-payment up to $55

Frames Insured 24 months

$0 Co-payment up to $150 allowance up to $75

Contact Lenses (only one option available per Benefit Frequency)

DL10-VIC-0119 TX 2

BENEFIT EyeMed Provider Non-Contracting Provider

Insured 12 months

Conventional $0 Co-payment up to $150 allowance up to $120

Disposable $0 Co-payment up to $150 allowance up to $120

Medically Necessary $0 Co-payment Paid In Full up to $210

Lens Options Insured 12 months

Standard Polycarbonate $40 Co-payment N/A

Standard Polycarbonate (For covered Dependent Children under 19 years of age)

$0 Co-payment up to $5

UV Treatment $15 Co-payment N/A

Tint, Solid or Gradient $15 Co-payment N/A

Standard Plastic Scratch Coating $0 Co-payment up to $5

Standard Progressive Lenses (add on to Bifocal)

$75 Co-payment up to $40

Premium Progressive Lenses (add on to Bifocal)

Tier 1 $95 Co-payment Tier 2 $105 Co-payment Tier 3 $120 Co-payment Tier 4 $75 Co-payment up to $120 allowance up to $40

Standard Anti-Reflective Coating $45 Co-payment N/A

Premium Anti-Reflective Coating Tier 1 $57 Co-payment Tier 2 $68 Co-payment Tier 3 80% of charge

N/A

Photochromic Lenses $75 Co-payment N/A

*Covered Dependent Children are eligible for more than one exam within 60 days of the initial exam if prescription has changed by 0.50 diopter sphere/cylinder > 20 degrees axis, or visual acuity improvement by one line on standard chart.

DL10-VIC-0119 TX 3

ELIGIBILITY AND EFFECTIVE DATE PROVISIONS

Who is eligible for this insurance?

The eligibility for this insurance is as indicated in the Schedule of Benefits.

The Eligibility Waiting Period is further defined in the Schedule of Benefits.

00001

When does Your Contributory insurance become effective?

You may enroll for coverage during the Annual Enrollment Period, unless You qualify because of a Change in Family Status.

Your Contributory coverage will become effective on the latest of the following dates if You are Actively at Work on that date:

1. If You enroll for coverage prior to the Policy Effective Date, the Policy Effective Date; or

2. If You enroll for coverage after the Policy Effective Date on the first of the month that falls on or next follows the date You sign the Enrollment Form; or

3. If You enroll during an Annual Enrollment Period, the next Anniversary Date following the Annual Enrollment Period.

Coverage requested because of a Change in Family Status will become effective on the first of the month that falls on or next follows the date You sign the Enrollment Form.

00003

Change in Family Status If You experience a Change in Family Status, You may enroll for coverage, apply for additional coverage, or request changes to Your current insurance coverage, provided the change is consistent with the Change in Family Status. For Your coverage to become effective, We must receive a completed Enrollment Form within 60 days of the Change in Family Status.

Change in Family Status means:

1. You get married or execute a domestic partner affidavit; or

2. You have a Dependent Child, or You adopt or become the legal guardian of a Dependent Child; or

3. Your Spouse dies or You become divorced; or

4. Your Dependent Child becomes emancipated or dies; or

5. Your Spouse is no longer employed, resulting in a loss of group insurance; or

6. You have a change in employment classification which results in You changing from part-time to full time, or full-time to part-time employment.

00004A

When does Dependent coverage become effective?

Your Dependent’s coverage will become effective on the latest of:

1. The date Your coverage becomes effective under the Policy, if You have enrolled for Dependent coverage on or before that date; or

2. The first day of the month following the date You enroll for Dependent coverage.

When does coverage for a new Spouse become effective?

Coverage for a new Spouse starts automatically on Your marriage. Your new Spouse will be a Covered Person for 31 days.

Your Spouse will cease to be a Covered Person unless:

1. You request, in writing within those 31 days continuation of such Dependent coverage; and

2. The required premium is paid. Premium will be charged from the date of marriage.

When does coverage for a newborn Child become effective?

If You have not previously elected Dependent Child coverage, coverage for a newborn Child starts automatically from the moment of birth if a Child is born to You. The newborn Child will be a Covered Person for 31 days. The newborn Child will cease to be a Covered Person after 31 days, unless:

1. You request in writing within those 31 days continuation of such Dependent Child coverage; and

2. The required premium is paid. Premium will be charged from the date of birth.

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If You currently have Dependent Child coverage, Your newborn Child will be automatically added to Your coverage.

Dependent Child coverage will also be extended to newly adopted, foster or step Children, as of the date they become financially dependent on You for support, provided they otherwise meet the definition of a Dependent Child.

00005

Will the Effective Date of coverage be delayed if Your Dependent is confined to a Hospital?

The Effective Date of coverage will be delayed if Your Dependent, other than a newborn Child, is confined in a Hospital on the date coverage would otherwise become effective. In such case, the Dependent’s coverage will become effective on the first day of the month that follows discharge from the Hospital.

00006

What is an Annual Enrollment Period?

Unless otherwise specified, Annual Enrollment Period means a period of time during which Employees may enroll for coverage or request changes to their benefit plan. The Annual Enrollment Period is shown on the Schedule of Benefits.

Initial requests for coverage or requests for changes to existing coverage made during the Annual Enrollment Period will become effective on the next Policy Anniversary Date.

00007

If You are not Actively at Work, when does coverage become effective?

If You are not Actively at Work on the date Your coverage would otherwise become effective, and Your absence is caused by an Injury, Illness or layoff, Your effective date for any initial coverage or increased coverage will be deferred until the first day You return to Active Work.

However, You will be considered Actively at Work on any day that is not Your regularly scheduled work day (including but not limited to a weekend, vacation or holiday) if You were Actively at Work on the immediately preceding scheduled work day and You were:

1. not Hospital Confined; or

2. disabled due to an Injury or Sickness.

00008

Eligibility after You Terminate Employment If Your coverage ends due to termination of employment, You must meet all the requirements of a new Employee if You are rehired by the Policyholder at a later date.

00009

What happens if We are replacing a Prior Policy?

Subject to the payment of premiums when due, We agree to waive the Actively at Work requirement if You:

1. were covered by a Prior Policy on the day immediately preceding the Policy Effective Date; and

2. You are on lay-off, non-medical leave of absence, or sabbatical leave; and

3. You are covered under an extension of benefits under the Prior Policy.

Coverage will continue for the first to occur of:

1. expiration of the balance of the extension of benefits under the Prior Policy; or

2. 12 months; or

3. the date the Policy terminates.

Prior Policy means the group vision insurance policy issued to the Policyholder immediately prior to the Effective Date of this Policy.

Changes to Your coverage A change in Your coverage may occur if:

1. You enroll for a different benefit amount; or

2. there is a Policy change; or

3. You enter another class and become eligible for a change in benefits.

DL10-VIC-0119 TX 5

If You are eligible for additional coverage due to a Policy change, the additional coverage will be effective on the date the Policy change is effective, as requested by the Policyholder and agreed upon by Us.

If a change results in additional coverage, for reasons other than a Policy change, the change will be effective the first of the month following the later of:

1. The date You enroll for the additional coverage; or

2. The date You become eligible for the additional coverage, if enrollment is not required.

In order for Your additional coverage to begin, You must be Actively at Work. Additional Contributory coverage is subject to Our receipt of premium.

If a change results in a decrease in coverage the change will take effect immediately.

Exception: Increases or decreases to Your coverage made during the Annual Enrollment Period will become effective on the next Policy Anniversary Date, provided You are Actively at Work on that day.

00010

VISION INSURANCE BENEFITS

Benefits are payable for each Insured Person, as shown in the Schedule of Benefits, for expenses incurred while this insurance is in force.

What are the EyeMed Provider Benefits?

The Insured Person must pay any Co-payment or any cost above the allowance shown in the Schedule of Benefits at the time the covered service is provided. Benefits will be paid to the EyeMed Provider who will file a claim with the company.

What are the Non-Contracting Provider Benefits?

The Insured Person must pay the Non-Contracting Provider the full cost at the time the covered service is provided and file a claim with the company. The company will reimburse the Insured Person for the Non-Contracting Provider benefits up to the maximum dollar amount shown in the Schedule of Benefits.

How Many Vision Examinations are Available?

An Insured Person is eligible for one Vision Examination in each Benefit Frequency.

What Vision Materials are Available?

If the Vision Examination covered by the Policy a Vision Examination results in an Insured Person needing corrective Vision Materials for the Insured Person’s visual health and welfare, those Vision Materials prescribed by the Provider will be supplied, subject to certain limitations and exclusions of the Policy, as follows:

1. Lenses provided one time in each Benefit Frequency.

2. Frame(s) provided one time in each Benefit Frequency.

3. Contact Lenses provided one time in each Benefit Frequency in lieu of lenses, Contact Lenses Fit and Follow-Up benefits apply only for covered Contact Lenses.

00011 TX

DL10-VIC-0119 TX 6

LIMITATIONS

Limitations:

1. Vision Examination and/or Vision Materials. Fees charged by a Provider for services other than a covered benefit must be paid in full, by the Insured Person, to the Provider. Such fees or materials are not covered under the Policy.

2. Benefit allowances provide no remaining balance for future use within the same Benefit Frequency.

EXCLUSIONS

No benefits will be paid for services or materials connected with or charges arising from:

1. orthoptic or vision training, subnormal vision aids and any associated supplemental testing;

2. Aniseikonic lenses;

3. medical and/or surgical treatment of the eye, eyes or supporting structures;

4. any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; safety eyewear;

5. services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof;

6. Plano (non-prescription) lenses and/or contact lenses;

7. non-prescription sunglasses;

8. two pair of glasses in lieu of bifocals;

9. services or materials provided by any other group benefit plan providing vision care;

10. certain name brand Vision Materials for which the manufacturer maintains a no-discount practice;

11. services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; or

12. lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available.

00013 TX

DL10-VIC-0119 TX 7

TERMINATION PROVISIONS

When does Your coverage under the Policy end?

Your coverage terminates on the earliest of the following dates:

1. the date on which the Policy is terminated; or

2. the end of the month after the date You stop making any required contribution toward payment of premiums; or

3. the effective date of an amendment to the Policy which terminates insurance for the class to which You belong; or

4. the earliest of:

a. the date You die; or

b. the end of the month after the date You are no longer a Member of a class eligible for this insurance; or

c. the end of the month after the date You request termination of coverage under the Policy; or

d. the first of the month following the date You reach age 99; or

e. the end of the month after the date You are no longer Actively at Work as a result of a Disability, layoff, or leave of absence or sabbatical, or military leave or Reserve National Guard.

Termination will not affect an eligible claim for a covered Loss which occurred while the coverage was in force.

You may continue to be eligible for coverage, as follows:

Disability Until the end of the twelfth month following the month in which the Disability began, if all premiums are paid when due.

Layoff Until the end of the month following the month during which the layoff began, if all premiums are paid when due.

Leave of Absence

Until the end of the month following the month during which the leave of absence began, if all premiums are paid when due, as governed by the Policyholder’s Human Resource policy on family and medical leaves of absence or in accordance with the FMLA provision below.

Sabbatical Until the end of the month following the sixth month in which the sabbatical began, if all premiums are paid when due.

Military Leave

Until the end of the twelfth month following the month in which the military leave began, if all premiums are paid when due.

Reserve National Guard

If You are a member of an organized United States Reserve Corps or National Guard Unit, coverage will continue while You are:

1. In attendance at annual field training, cruise or other active duty training period of less than 60 days

(except while attending a service school lasting beyond 60 days, in which case coverage will extend for the duration of the school); or

2. on the way to or from such training; or

3. participating in an authorized periodic inactive duty training, assembly or other inactive duty training authorized by unit orders; or

4. participating as a member of Your unit in an authorized parade, exhibition or ceremony.

For the purposes of this provision, Disability means You are unable to perform all of the Material and Substantial Duties of Your Regular Occupation.

00015 TX

Will coverage be continued if You are eligible for leave under FMLA?

In the event You are eligible for and the Policyholder approves a leave of absence under the Family and Medical Leave Act of 1993 and its amendments (FMLA), or any applicable state family and medical leave law provided the Policyholder continues to pay Your required premium, Your coverage will continue for a period of up to the later of:

1. the leave period permitted by the federal FMLA; or

2. the leave period permitted by applicable state law.

You are eligible for leave under this Act in order to provide care:

1. After the birth of a Child; or

DL10-VIC-0119 TX 8

2. After the legal adoption of a Child; or

3. After the placement of a foster Child in Your home; or

4. To a Spouse, Child or parent due to their serious Illness; or

5. For Your serious health condition; or

6. For any event later added by amendment to the Act.

During Your FMLA period:

1. The Policyholder must remit the premium required by the Policy; and

2. Coverage will terminate if You do not return to work as scheduled according to the terms of Your leave of absence agreement with the Policyholder.

00016

When does Dependent coverage end?

Dependent coverage will end on the earliest of:

1. the last day of the month You are no longer an Employee (except in the case of Disability, layoff, or leave of absence or sabbatical, or military leave or Reserve National Guard as set forth above); or

2. the date on which the Policy is terminated; or

3. the last day of the month You stop making any required contribution toward payment of premiums; or

4. the effective date of an amendment to the Policy which terminates insurance for the class to which You belong; or

5. the last day of the month You:

a. are no longer a member of a class eligible for this insurance; or

b. request termination of coverage under the Policy; or

c. reach age 99; or

d. are retired or pensioned; or

6. the date a Dependent Child or Spouse no longer meets the Policy definition of Dependent; or

7. the first of the month following 90 days after the date of Your death. Premium will not be payable during this period.

Coverage will continue past the age limit for Dependent Children who are primarily dependent on You for support and who cannot work to support themselves due to a physical or mental incapacity which began before the age limit was reached.

Written proof of such incapacity must be provided to Us on request.

00017 TX

DL10-VIC-0119 TX 9

GENERAL PROVISIONS

Entire Contract; Changes The Entire Contract consists of:

1. The Group Insurance Policy;

2. The Application;

3. This Certificate;

4. The Enrollment Forms of the persons Insured, including any individual statements; and

5. Any riders; endorsements; or amendments to the Policy or the Certificate.

Coverage under the Policy can be amended by mutual consent of the Policyholder and Us. No change in the Policy is valid unless approved in writing by one of Our officers. No agent has the right to change the Policy or to waive any of its provisions.

Statements on the Application All statements made in any signed Application, or other written and signed statement, are considered representations and not warranties (absolute guarantees). No representation by:

1. the Policyholder in applying for the Policy will make it void unless the representation is contained in the signed

Application or other written and signed statement; or

2. any Employee in enrolling for insurance under the Policy will be used to reduce or deny a claim unless a copy of the

Application for Insurance or other written and signed statement, if applicable, has been signed by the Employee and has been given to the Employee.

Legal Actions Unless otherwise provided by federal law, no legal action brought to recover on the Policy of any kind may be filed against Us:

1. until 60 days after proof of claim has been given; or

2. more than 3 years after proof must be filed, unless the law in the state where You live allows a longer period of time.

Clerical Error Clerical error or omission by Us to the Policyholder will not:

1. Prevent You from receiving coverage, if You are entitled to coverage under the terms of the Policy; or

2. Cause coverage to begin or coverage to continue for You when the coverage would not otherwise be effective.

If the Policyholder gives Us information about You that is incorrect, We will:

1. Use the facts to decide whether You have coverage under the Policy and in what amounts; and

2. Make a fair adjustment of the premium.

Incontestability The validity of the Policy shall not be contested, except for non-payment of premiums, after it has been in force for two years from the date of issue. No statement You made relating to Your insurability under the Policy will be used to contest the validity of the insurance with respect to which such statement was made after such insurance has been in force for two years during Your lifetime, and in no event unless the statement is contained in a written instrument signed by You and a copy is given to You or to Your beneficiary.

Premium Provisions Premiums are payable in United States dollars on or before their due dates. The Policyholder has agreed to deduct from Your pay any premiums payable for Your Contributory coverage. The Policyholder agrees to and is responsible for remitting such premiums for the entire time coverage under the Policy is in effect.

Premium charges for increases in insurance amounts becoming effective during a Policy month will begin on the next premium due date. Premium charges for insurance terminating during a Policy month will cease at the end of the month in which such insurance terminates. This method of charging premium is for accounting purposes only. It will not extend any insurance coverage beyond the date it would otherwise have become effective or terminated.

Misstatement of Age If You have misstated Your age or the age of a Dependent, the true age will be used to determine:

1. the effective date or termination date of insurance; and

2. the amount of insurance; and

DL10-VIC-0119 TX 10

3. any other rights or benefits.

Premiums will be adjusted to reflect the premiums that You should have been paid if the true age had been known.

Conformity with State Statutes and Regulations If any provision of the Policy conflicts with the statutes and regulations of the state in which the Policy was issued or delivered, it is automatically changed to meet the minimum requirements of the statute.

Assignment Benefits under the Policy may not be assigned.

00018

DL10-VIC-0119 TX 11

UNIFORM CLAIM PROVISIONS

Initial Notice of Claim We must receive written notice of claim within 30 days of receiving services, or as soon as reasonably possible. The Policyholder can assist with the appropriate telephone number and address of Our Claim Department. Notice may be sent to Our Claim Department at the address shown on the claim form or given to any authorized agent of Ours.

Claim Forms Within 15 days of Our being notified in writing of a claim, We will supply the claimant with the necessary claim forms. If the appropriate claim forms are not received within 15 days, then the claimant will be considered to have met the requirements for written Proof only if We receive written Proof, which describes the occurrence, extent and nature of the loss for which claim is made.

Proof of Loss We must receive written Proof within 90 days of the date You receive services or supplies. If it is not possible to give Us written Proof within 90 days, the claim is not affected if the Proof is given as soon as possible. However, unless the claimant is legally incapacitated, written Proof must be given no later than one year after the time Proof is otherwise due.

No benefits are payable for claims submitted more than 1 year after the time Proof is due. However, benefits may be paid if it can be shown that:

1. It was not reasonably possible to give written Proof during the one year period, and

2. Proof was given as soon as was reasonably possible.

We will give You written response to Your claim, usually within 45 days. The time for decision may be extended for two additional 30 day periods provided that, prior to any extension period, We notify You in writing that an extension is necessary due to matters beyond Our control, identify those matters and gives the date by which We expect to render a decision. If the extension is due to Your failure to submit information necessary to decide Your claim, the time for decision shall be tolled from the date on which We send You notice of the extension until the date We receive Your response to Our request. This period will be no longer than 45 days after We have requested the information. At that time We will decide Your claim based on the information We have at that time.

Who will receive Your Insurance Benefits?

EyeMed Provider benefits are payable to You or to Your Provider. Non-Contracting Provider benefits are payable to You. Any benefits payable on, or after, Your death, will be payable to Your Estate.

00019 TX

Do I have the Right to Appeal a Claim Denial?

If Your claim is denied, in whole or in part, You will receive a written notice giving the following:

- the reason or reasons for the denial;

- the Policy provisions on which the denial is based;

- an explanation of what other material or information, if any, may be needed to process the claim and why it is needed;

- the steps that You have to follow to have the claim reviewed;

- a statement that You have the right to bring a civil action under section 502(a) of ERISA after You appeal Our decision and after You receive a written denial on appeal; and

- if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the denial, either (i) the specific rule, guideline, protocol or other similar criterion; or (ii) a statement that such a rule, guideline, protocol or other similar criterion was relied upon in making the denial and that a copy will be provided free of charge to You upon request; and

- if denial is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to Your medical circumstances, or (ii) a statement that such explanation will be provided to You free of charge upon request.

If the claim has been denied, in whole or in part, You can appeal the denial to Us for a full and fair review. You have at least 180 days to appeal from the claim denial.

You may:

a. request a review upon written application within 180 days of the claim denial;

b. request, free of charge, copies of all documents, records and other information relevant to Your claim; and

DL10-VIC-0119 TX 12

c. submit written comments, documents, records and other information relating to Your claim, without regard to whether such information was submitted or considered in the initial benefit determination.

We will make a decision no more than 45 days after We receive Your appeal. The time for decision may be extended for one additional 45 day period provided that, prior to the extension, We notify You in writing that an extension is necessary due to special circumstances, identifies those circumstances and gives the date by which it expects to render its decision. If Your claim is extended due to Your failure to submit information necessary to decide Your claim on appeal, the time for Your decision shall be tolled from the date on which the notification of the extension is sent to You until the date We receive Your response to the request.

The decision on appeal will provide the following:

- the reason or reasons for the decision;

- the Plan provision on which the decision is based;

- a statement that You are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to Your claim for benefits;

- a statement of the claimant’s right to bring an action under section 502(a) of ERISA;

- if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the decision either (i) the specific rule, guideline, protocol or other similar criterion; or (ii) a statement that such a rule, guideline, protocol or other similar criterion was relied upon in making the decision and that a copy will be provided free of charge to You upon request;

- if the decision is based on medical judgment, either (i) an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to Your medical circumstances, or (ii) a statement that such explanation will be provided to You free of charge upon request; and

- the following statement: “You and Your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact Your local U.S. Department of Labor Office and Your State insurance regulatory agency.”

00020

DL10-VIC-0119 TX 13

GENERAL DEFINITIONS

Actively at Work or Active Work means that You must:

1. work for the Policyholder on a full-time active basis; or

2. work at least the minimum number of hours set forth in the Schedule of Benefits and either:

a. work at the Policyholder’s usual place of business; or

b. work at a location to which the Policyholder’s business requires You to travel; and

3. not be a temporary or seasonal Employee; and

4. be paid regular earnings by the Policyholder.

You will be considered Actively at Work if You were actually at work on the day immediately preceding:

1. a weekend (except for one or both of these days if they are scheduled days of work);

2. holidays (except when such holiday is a scheduled work day);

3. paid vacations;

4. any non-scheduled work day;

5. excused leave of absence (except medical leave and lay-off);

6. emergency leave of absence (except emergency medical leave); and

7. You were not Hospital Confined or disabled due to an Injury or Illness.

00021

Anniversary Date means the annual month and day that corresponds with the Policy Effective Date.

00022

Annual Enrollment Period means the annual timeframe defined in the Schedule of Benefits when Employees can make benefit changes.

00023

Application means the document which sets forth the eligible classes, the amounts of insurance, and other relevant information pertaining to the plan of insurance for which the Policyholder applied.

00024

Benefit Frequency means the period of time in which a benefit is payable.

The Benefit Frequency begins on the later of the Insured Person's Effective Date or last date services were provided to the Insured Person. Each new Benefit Frequency begins at the expiration of the previous Benefit Frequency.

00025

Certificate means this Vision Insurance Certificate.

00026

Child(ren) means:

1. Your natural or step Child or Child of Your Registered Domestic Partner under the age stated in the Schedule of Benefits;

or

2. a Child under the age stated in the Schedule of Benefits placed with You for adoption from the date of placement or the date You are party in a suit in which You seek the adoption of the Child. Eligibility will continue unless the Child is removed from placement; or

3. an unmarried Child of Your Child who is within the age limits set forth in the Schedule of Benefits and who is Your dependent for federal income tax purposes at the time application for coverage of the Child of Your Child is made.

Coverage for a Child of Your Child may not be terminated solely because the Child is no longer a Dependent for tax purposes; or

4. a Child for who You are required to insure under a medical support order issued under Chapter 154, Family Code or enforceable by a court of the State of Texas.

00027 TX

Co-payment means the designated amount, if any, shown in the Schedule of Benefits each Insured Person must pay to a Provider before benefits are payable for a covered Vision Examination and or Vision Materials per Benefit Frequency.

00028

DL10-VIC-0119 TX 14

Computer Display means a personal computer monitor, personal laptop or mainframe terminal. It does not include any handheld electronic devices.

00029

Contributory means You pay all or a portion of the premium for this insurance coverage.

00032

Covered Person means an Employee or Eligible Dependent covered under the Policy.

00033

Dependent or Eligible Dependent means:

1. Your lawful Spouse or Registered Domestic Partner; and/or

2. Your Child(ren) who are not in active military service; and are within the age limits set forth in the Schedule of Benefits.

00034

Employee or Eligible Employee means an Actively at Work, full-time Employee working in the United States of America as shown in the Schedule of Benefits whose principal employment is with the Policyholder and who is reported on the Policyholder’s records for Social Security and withholding tax purposes.

00035

Enrollment Form means a form acceptable to Us that You complete to enroll for coverage under the Policy.

00036

EyeMed Provider means a Provider who has signed an agreement with EyeMed.

00041 TX

Hospital Confinement or Confinement means the assignment to a bed as an inpatient in a Hospital on the advice of a Physician or confinement in an observation unit within a Hospital for a period of no less than 20 continuous hours on the advice of a Physician.

00040

Insured(s) means an Employee or Dependent covered under the Policy.

00042

Insured Person(s) means the Insured. Insured Person will also include the Insured’s Dependents, if shown on the Insured’s identification card, if enrolled.

00043

Male Pronoun whenever used includes the female.

00047

Material and Substantial Duties means duties that are normally required for the performance of Your Regular Occupation which cannot be reasonably omitted or modified.

00048

Medically Necessary Contact Lenses means:

1. Keratoconus where the Insured Person is not correctable to 20/30 in either or both eyes using standard spectacle lenses, or the Provider attests to the specified level of visual improvement;

2. High Ametropia exceeding -10D or +10D in spherical equivalent in either eye;

3. Anisometropia of 3D in spherical equivalent or more; or

4. vision for an Insured Person can be corrected two lines of improvement on the visual acuity chart when compared to best corrected standard spectacle.

00049

Non-Contract or Non-Contracting Provider means a Provider, who has not signed an agreement with EyeMed.

00053 TX

Policy means the contract between the Policyholder and Us including the Application, this Certificate and any amendments, riders or endorsements.

00056

Policy Effective Date or Effective Date means the date stated on the Schedule of Benefits.

00057

DL10-VIC-0119 TX 15

Policyholder means the person, firm, or institution to whom the Policy was issued. Policyholder also means any covered subsidiaries or affiliates set forth on the face of the Policy.

00058 TX

Proof means evidence satisfactory to Us that the Covered Person has received services or supplies listed in the Schedule of Benefits.

00062

Provider means a licensed physician, optometrist, therapeutic optometrist or opthalmologist who is operating within the scope of his or her license or a dispensing optician.

00063 TX

Registered Domestic Partner means an adult of the same or opposite gender who has an emotional, physical and financial relationship to You, similar to that of a Spouse, as evidenced by the following:

1. You and Your Domestic Partner share financial responsibility for a joint household and intend to continue an exclusive relationship indefinitely;

2. You and Your Domestic Partner each are at least eighteen (18) years of age;

3. You and Your Domestic Partner are both mentally competent to enter into a binding contract;

4. You and Your Domestic Partner share a residence and have done so for at least 12 months;

5. Neither You nor Your Domestic Partner are married to or legally separated from anyone else;

6. You and Your Domestic Partner are not related to one another by blood closer than would bar marriage; and

7. Neither You nor Your Domestic Partner is a Domestic Partner of anyone else.

Where the laws of the governing jurisdiction mandate a definition of Registered Domestic Partner other than shown above, that definition will be used in the Policy.

00064

Regular Occupation means the occupation that You are routinely performing when Your insurance terminates due to Disability. We will look at Your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for Your Policyholder or at Your specific location.

00065

Schedule of Benefits means the schedule which is a part of this Certificate.

00067

Spouse means lawful Spouse. Spouse will include Your Registered Domestic Partner.

00068

Vision Examination means a comprehensive ophthalmological service as defined in the Current Procedural Technology (CPT) and the Documentation Guidelines listed under "Eyes-examination items". Comprehensive ophthalmological service describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated by examination, biomicroscopy, examination with cyclopedia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.

00069

Vision Materials means those materials shown in the Schedule of Benefits.

00070

Voluntary means coverage for which You pay 100% of the premium.

00071

We, Our and Us means Dearborn Life Insurance Company.

00072

You, Your and Yours means the Employee to whom this Certificate is issued and whose insurance is in force under the terms of the Policy.

00073

DL10-VIC-0119 TX 16

NOTICE

CONTINUATION COVERAGE RIGHTS UNDER COBRA

INTRODUCTION

You are receiving this notice because You have recently become covered under Your Employer's group health plan (the Plan).

This notice contains important information about Your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage may be available to You and to other members of Your family who are covered under the Plan when You would otherwise lose Your group health coverage. Contact Your Employer to determine if You are eligible for COBRA continuation coverage.

This notice generally explains:

● COBRA continuation coverage,

● When it may become available to You and Your family, and

● What You need to do to protect the right to receive it.

This notice gives only a summary of Your COBRA continuation coverage rights. For more information about Your rights and obligations under the Plan and under federal law, You should either contact the Plan Administrator or review the Certificate or Certificate of Coverage provided to You by Your Plan.

The Plan Administrator of the Plan is named by the Employer or by the group health plan. Either the Plan Administrator or a third party named by the Plan Administrator is responsible for administering COBRA continuation coverage. Contact Your Plan Administrator for the name, address, and telephone number of the party responsible for administering Your COBRA continuation coverage.

COBRA CONTINUATION COVERAGE

COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a "qualifying event." Specific qualifying events are listed later in this notice. COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and Dependent children of employees may be qualified beneficiaries. Under the Plan, generally most qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. Contact Your Employer and/or COBRA Administrator for specific information for Your Plan.

If You are an employee, You will become a qualified beneficiary if You will lose Your coverage under the Plan because either one of the following qualifying events happens:

(1) Your hours of employment are reduced; or

(2) Your employment ends for any reason other than Your gross misconduct.

If You are the spouse of an employee, You will become a qualified beneficiary if You will lose Your coverage under the Plan because any of the following qualifying events happens:

(1) Your spouse dies;

(2) Your spouse's hours of employment are reduced;

(3) Your spouse's employment ends for any reason other than his or her gross misconduct;

(4) Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or

(5) You become divorced or legally separated from Your spouse.

Your Dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens:

(1) The parent-employee dies;

(2) The parent-employee's hours of employment are reduced;

(3) The parent-employee's employment ends for any reason other than his or her gross misconduct;

(4) The parent-employee becomes enrolled in Medicare (Part A, Part B, or both);

(5) The parents become divorced or legally separated; or

(6) The child stops being eligible for coverage under the Plan as a "Dependent child."

DL10-VIC-0119 TX 17

If the Plan provides health care coverage to retired employees, the following applies:

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Your employer, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee is a qualified beneficiary with respect to the bankruptcy. The retired employee's spouse, surviving spouse, and Dependent children will also be qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred

The Employer must notify the Plan Administrator within 30 days when the qualifying event is:

● The end of employment;

● The reduction of hours of employment;

● The death of the employee;

● In the event of retired employee health coverage, commencement of a proceeding in bankruptcy with respect to the employer; or

● The enrollment of the employee in Medicare (Part A, Part B, or both).

For the other qualifying events (divorce or legal separation of the employee and spouse or a Dependent child's losing eligibility for coverage as a Dependent child), You must notify the Plan Administrator. The Plan requires You to notify the Plan Administrator within 60 days after the qualifying event occurs. Contact Your Employer and/or the COBRA Administrator for procedures for this notice, including a description of any required information or documentation.

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. For each qualified beneficiary who elects COBRA continuation coverage, COBRA continuation coverage will begin on the date that Plan coverage would otherwise have been lost.

COBRA continuation coverage is a temporary continuation of coverage. COBRA continuation coverage may last for up to 36 months when the qualifying event is:

● The death of the…