8-Vision Plan.pdf

Superior Vision of Texas PO Box 509 Troy, NY 12181 (800) 507-3800 superiorvision.com 1125-BSv2/TX superiorvision.com

(800) 507-3800

Vision plan benefits for City of Lewisville

Copays Services/frequency

Exam1 $15 Exam 12 months

Eyewear2 $20 Frame 12 months

Lenses 12 months

Contact lenses 12 months

(Based on date of service)

Benefits through Superior Select Southwest network In-network Out-of-network Exam Covered in full Up to $35 retail Frames $150 retail allowance Up to $70 retail Lenses (standard) per pair Single vision Covered in full Up to $25 retail Bifocal Covered in full Up to $40 retail Trifocal Covered in full Up to $45 retail Progressive See description3 Up to $45 retail Lenticular Covered in full Up to $80 retail Contact lenses4 $150 retail allowance Up to $80 retail Medically necessary contact lenses Covered in full Up to $150 retail LASIK vision correction5 $200 allowance

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Eye exam copay is a single payment due to the provider at the time of service 2 Eyewear copay applies to eyeglass lenses / frame and contact lenses. Eyewear copay is a single payment that applies to the entire purchase of eyeglasses (frame and lenses) 3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 4 Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit 5 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations

Discount features

Discounts on covered materials6

These discounts apply to the glasses and contacts that are covered under the vision benefits.

Frames: 20% off amount over allowance Conventional contacts 20% off amount over allowance Disposable contact 10% off amount over allowance

Lens type* Member out-of-pocket6

Scratch coat $15 Ultraviolet coat $12 Tints, solid $15 Tints, gradient $18 Polycarbonate $40 Blue light filtering $15 Digital single vision $30 Progressive lenses Standard/Premium/Ultra/Ultimate $55 / $110 / $150 / $225 Anti-reflective coating Standard/Premium/Ultra/Ultimate $50 / $70 / $85 / $120 Polarized lenses $75 Plastic photochromic lenses $80 High Index (1.67 / 1.74) $80 / $120

* The above table highlights some of the most popular lens type and is not a complete listing. This table outlines member out-of-pocket costs5 and are not available for premium/upgraded options unless otherwise noted.

Discounts on non-covered exam, services and materials6

Exams, frames, and prescription lenses: 30% off retail Contacts, miscellaneous options: 20% off retail Disposable contact lenses: 10% off retail Retinal imaging: $39 maximum out-of-pocket

Laser vision correction (LASIK)6

Laser vision correction (LASIK) is a procedure that can reduce or eliminate your dependency on glasses or contact lenses. This corrective service is available to you and your eligible dependents at a special discount (20-50%) with your Superior Vision plan.

Contact QualSight LASIK at (877) 201-3602 for more information.

Hearing discounts6 A National Hearing Network of hearing care professionals, featuring Your Hearing Network, offers Superior Vision members discounts on services, hearing aids and accessories. These discounts should be verified prior to service.

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan.

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan.

Please check with your Human Resources department if you have any questions.

6Not all providers participate in Superior Vision Discounts, including the member out-of-pocket features. Call your provider prior to scheduling an appointment to confirm if he/she offers the discount and member out-of-pocket features. The discount and member out-of-pocket features are not insurance. Discounts and member out-of-pocket are subject to change without notice and do not apply if prohibited by the manufacturer. Lens options may not be available from all Superior Vision providers/all locations.

pif4t Su eriorVision'

GROUP CONTRACT

SUPERIOR VISION OF TEXAS

11090 White Rock Road, Suite 175

Rancho Cordova, CA 95670

1- 800- 507- 3800

I3 from VersantHealth

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P

IMPORTANT NOTICE AVISO IMPORTANTE

To obtain information or make a complaint:

Para obtener informacion o para someter una queja:

You may call Superior Vision of Texas' toll free Usted puede Ilamar al numero de telefono gratis de telephone number for information or to make a Superior Vision of Texas' para informacion o para complaint at:

someter una queja al:

1- 800- 507- 3800 1- 800- 507- 3800

You may also write to Superior Vision of Texas at:

Usted tambien puede escribir a Superior Vision of

Texas al:

11090 White Rock Road, Suite 175

Rancho Cordova, CA 95670 11090 White Rock Road, Suite 175

Rancho Cordova, CA 95670

You may contact the Texas Department of Insurance to obtain information on companies, coverage, rights

Puede comunicarse con el Departamento de Seguros or complaints at:

de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al:

1- 800- 252- 3439 1- 800- 252- 3439

You may write the Texas Department of Insurance:

Puede escribir al Departamento de Seguros de Texas:

P. O. Box 149104

Austin, Texas 78714- 9104 P. O. Box 149104

FAX#( 512) 475- 1771

Austin, Texas 78714- 9104

Web: http:// www. tdi.. gov

FAX#( 512) 475- 1771

E- mail: ConsumerProtection@tdi. texas. gov Web: http:// www.tdi.state. gov E- mail: ConsumerProtection@tdi. texas. gov

PREMIUM CLAIM OR DISPUTES: Should you have a dispute concerning your premium or about a DISPUTAS SOBRE PRIMAS 0 RECLAMOS: Si claim you should contact Superior Vision of Texas tiene una disputa concerniente a su prima o a un first. If the dispute is not resolved, you may contact reclamo, debe comunicarse con Superior Vision of the Texas Department of Insurance. Texas primero. Si no se resuelve la disputa, puede entonces comunicarse con el departamento( TDI).

ATTACH THIS NOTICE TO YOUR POLICY:

This notice is for information only and does not UNA ESTE AVISO A SU POLIZA: Este aviso es become a part or condition of the attached document. solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto.

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SUPERIOR VISION OF TEXAS

and

CITY OF LEWISVILLE

GROUP CONTRACT

Table of Contents

Section Page

1. COVERAGE TYPE 2

2. PREMIUMS 2

3. TERM 3

4. CONTRACT ADMINISTRATION 3

5. CANCELLATION/ TERMINATION 3

6. RENEWAL 4

7. ASSIGNMENT 5

8. AMENDMENT 5

9. ENTIRE CONTRACT 5

10. GOVERNING LAW 5

11. INCONTESTABILITY 5

12. MEMBER CERTIFICATE 6

13. ELECTRONIC DELIVERY 6

14. COUNTERPARTS BY FACSIMILE OR EMAIL 6

ATTACHMENT- Member Certificate

PLEASE READ THIS CONTRACT CAREFULLY. This is a legal contract between Block Vision of Texas, Inc. d/ b/ a Superior Vision of Texas

Superior Vision of Texas") and the above- listed Group.

IMPORTANT CANCELLATION INFORMATION. Please read the provision entitled Cancellation/ Termination, found on page 3.

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Superior Vision of Texas and City of Lewisville. (" Group") hereby promise and agree that Superior Vision of Texas shall provide or arrange for the provision of vision care Covered Services to Members affiliated with the Group in accordance with this Agreement and the attached Member Certificate, which is incorporated into and made a part of this

Group Contract. All of the defined terms in the Member Certificate have the same meaning in this Group Contract.

1. COVERAGE TYPE: Plan Code L0478

2. PREMIUMS:

A) Subscriber 4. 15 per Member per month

Subscriber/ Spouse 7. 90 per Member per month

Subscriber/ Child( ren) $ 7. 80 per Member per month

Subscriber/ Family 12. 20 per Member per month

All premiums for the initial month of coverage shall be remitted by the Group to Superior Vision of Texas on the 15th of the month preceding the initial month of coverage, accompanied by a list of persons to be covered hereunder.

On or about the 15th day of each calendar month thereafter, Superior Vision of Texas will send the Group an alphabetized list of Subscribers and a bill for the next month' s coverage. On or before the 1" day of each month of coverage, the Group shall remit the total Premium to Superior Vision of Texas. Premiums are guaranteed for the initial contract term of 48 months. However, Premiums may be adjusted at any time by Superior Vision of Texas upon sixty( 60) days notice to the Group if, in Superior Vision of Texas' sole opinion, its liability

e. g., for taxes or services ( coverage)) is altered by any state or federal law, which notice shall set forth the amount of the increase and the date on which the increase will take effect.

B) A grace period of 30 days will be granted for the payment of each premium falling due after the first premium. During the grace period, the contract shall continue in force. A charge may be added to the premium by Superior Vision of Texas for late payment received within the grace period. If payment is not received within the 30 days, coverage may be canceled after the 30th day and the terminated Members may be held liable for the cost of services received during the grace period.

C) In addition to any other premiums for which the Group is liable, the Group is liable for a Member' s premiums from the time the Member is no longer part of the Group eligible for coverage under this Group Contract until the end of the month in which the Group notifies Superior Vision of Texas that the Member is no longer part of the Group eligible for coverage under this Group Contract.

The Member remains covered by this Group Contract until the end of that period.

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3. TERM:

The initial Effective Date of coverage shall be October 1, 2022. The term of this

Group Contract shall begin on that date and continue for 4 years ( s) thereafter, unless sooner terminated in accordance with this contract or the Member Certificate.

4. CONTRACT ADMINISTRATION:

A) The Group will cooperate with Superior Vision of Texas with respect to Superior Vision of Texas' enrolling persons eligible to enroll hereunder and in obtaining authorized payroll withholding from Subscribers to the extent applicable. The Group shall provide Superior of Texas with an updated list indicating Members to be added or deleted on a monthly basis.

B) Superior Vision of Texas shall receive copies from the Group of all signed enrollment and/ or change forms; shall be permitted to inspect the Group' s records for information pertaining to eligibility, enrollment, and payment of Premiums hereunder; and shall be permitted to make copies thereof at any reasonable time upon reasonable prior notice to the Group.

5. CANCELLATION/ TERMINATION

A) Coverage under this Contract may be canceled by Superior Vision of Texas under the following circumstances:

1. For a Member, in the case of

a) nonpayment of amounts due under the contract, coverage may be canceled after not less than 30 days' written notice, except no written notice will be required for failure to pay premium;

b) fraud or intentional misrepresentation of a material fact, except as described in section 11, coverage may be canceled after not less than 15 days' written notice;

c) fraud in the use of services or facilities, coverage may be canceled after not less than 15 days' written notice;

d) failure to meet eligibility requirements, coverage may be canceled immediately, other than the requirement that the

Subscriber reside, live or work in the Service Area, subject to applicable continuation of coverage provisions;

e) misconduct detrimental to safe plan operations and the delivery of services, coverage may be canceled immediately;

0 failure of the Member and a Provider to establish a satisfactory patient- provider relationship if it is shown that Superior Vision

BVT d/ b/ a SVT- GC- 11/ 14 3) of Texas has provided the Member with the opportunity to select an alternative Provider, the Member is notified in writing at least 30 days in advance that Superior Vision of Texas considers the patient- Provider relationship to be unsatisfactory and specifies the changes that are necessary in order to avoid termination, and the Member has failed to make such changes, coverage may be canceled at the end of the 30 day period; or

g) failure of the Subscriber to reside, live or work in the Service

Area, after 30 days' written notice, provided that coverage for a child who is the subject of a medical support order will not be canceled for failure to reside, live or work in the Service Area.

2. For a Group, in the case of

a) nonpayment of premium, after the end of the thirty( 30) days grace period described in Section 2( B) hereof, but the Group shall remain liable for premiums accrued during this 30 day period;

b) fraud on the part of the Group, after 15 days' written notice;

c) Group' s failure to meet the qualifying participation or contribution requirements for a period of at least six consecutive months. Superior Vision of Texas may terminate coverage upon the first renewal date following the end of the six-month consecutive period during which the qualifying participation or contribution requirement was not met; or

d) Group no longer having any Member that resides, lives or works in the Service Area, after 30 days' written notice.

B) Either the Group or Superior Vision of Texas may terminate this Contract effective as of any Renewal Date, by providing at least sixty ( 60) days' prior written notice to the other party. In the case of a material change by Superior Vision of Texas to any provision of this Group Contract, Group may cancel this Group Contract after not less than 30 days' written notice to Superior Vision of Texas.

6. RENEWAL

Upon expiration of the original term, this Contract shall be automatically renewed on an annual basis effective on the Renewal Date, unless otherwise terminated in accordance with Section 5 hereof Except as otherwise herein provided, each amendment to this Contract, including a change in Premiums or Covered Services, proposed by either party in writing at least sixty ( 60) days prior to the Renewal Date shall become effective on that Renewal Date.

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7. ASSIGNMENT

The Group shall not assign this Contract or its rights hereunder nor delegate its duties hereunder without the prior written consent of Superior Vision of Texas.

8. AMENDMENT

Except as otherwise provided, this Contract may be amended only in writing signed by both parties. All amendments thereafter shall be attached hereto and made a part of this Contract. To be valid, any amendment must be approved by an officer of Superior Vision of Texas. No agent ( other than an officer of Superior Vision of Texas) has the authority to amend this Contract on behalf of Superior Vision of Texas or waive any of its provisions.

9. ENTIRE CONTRACT

This Contract, including the attached Member Certificate and any amendments thereto, and the Group Application, represents the entire agreement between the parties with respect to the subject matter. The invalidity or unenforceability of any Section or sub- Section of this Contract shall not affect the validity or enforceability of the remaining Sections or sub- Sections hereof

10. GOVERNING LAW

This Contract shall be construed for all purposes as a legal document and shall be interpreted and enforced in accordance with pertinent laws and regulations of the State of Texas. If this Contract or the Membership Certificate contains any provision not in conformity with Texas law, it shall not be rendered invalid but shall be construed and applied as if it were in full compliance with such law.

11. INCONTESTABILITY

All statements made by a Subscriber on the enrollment application shall be considered representations and not warranties. The statements are considered to be truthful and are made to the best of the Subscriber' s knowledge and belief. A statement may not be used in a contest to void, cancel, or non- renew an enrollee' s coverage or reduce benefits unless: ( i) it is in a written enrollment application signed by the Subscriber; and ( ii) a signed copy of the enrollment application is or has been furnished to the Subscriber or the Subscriber' s personal representative. Superior

Vision of Texas may only contest coverage because of fraud or intentional misrepresentation of material fact on the enrollment application.

Superior Vision of Texas may increase its Premium to the appropriate level if Superior Vision of Texas determines that Subscriber made a material misrepresentation on the application. Superior Vision of Texas must provide the

Group thirty- one ( 31) days prior written notice of any Premium rate change pursuant to this Section.

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12. MEMBER CERTIFICATE

The Covered Services ( Benefits) as well as any applicable exclusion, the

Continuation of Benefits provisions, and the grievance procedures are described in the Member Certificate. Superior Vision of Texas will provide the Group with the Member Certificate to be delivered to each Subscriber. Any direct conflict between the Group Contract and the Member Certificate will be resolved according to the terms which are most favorable to the Subscriber.

13. ELECTRONIC DELIVERY.

The parties agree that this Group Contract, the Member Certificate including the attachments thereto, and any other plan documents or notices may be delivered electronically. Group agrees to deliver the Member Certificate including the attachments thereto and any other plan documents or notices to Subscribers.

14. COUNTERPARTS BY FACSIMILE OR EMAIL

This Group Contract may be executed in one or more counterparts, each of which shall be deemed an original, but all of which together shall constitute a single instrument.

To the extent any counterpart to this Group Contract is delivered by facsimile machine or electronic mail it shall be treated in all manner and respects as an original signed version thereof

BLOCK VISION OF TEXAS, INC. GROUP

D/B/A SUPERIOR VISION OF TEXAS Name: ty of Lewisville

By: By: V a-44114, 1LC

Title: Sr. Vice President Title:

A

410- t ` Ili.. «I

Date: Date: ( 71' I

Address/ Telephone/ Fax/ Email Address/ Telephone/ Fax/ Email

Address: Address:

11090 White Rock Road, Suite 175 151 West Church Street

Rancho Cordova, CA 95670 Lewisville, TX 75029

Attention: Commercial Group Administration Attention: Britini Brattlof

Telephone: 1- 800- 507- 3800 Telephone: 972- 219- 3453

Facsimile: 1- 916- 852- 2290 Facsimile:

Email: commercialgroupadmin@superiorvision. com Email Address:

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