Attachment H – Vision Benefits.pdf

additional complete pair of prescription eyeglasses non-covered items, including non-prescription sunglasses

40%

OFF

20%

OFF

SUMMARY OF BENEFITS

• 866.804.0982

• eyemed.com

• EyeMed Members App

• For LASIK, call

1.800.988.4221

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Gloucester County Public Schools

Find an eye doctor (Insight Network)

VISION CARE

SERVICES

IN-NETWORK

MEMBER COST

OUT-OF-NETWORK

MEMBER REIMBURSEMENT

EXAM SERVICES

Exam $10 copay Up to $40 Retinal Imaging Up to $39 Not covered

CONTACT LENS FIT AND FOLLOW-UP

Fit and Follow-up - Standard Up to $40 Not covered Fit and Follow-up - Premium 10% off retail price Not covered

FRAME

Frame $0 copay; 20% off balance over $130 allowance Up to $91

LENSES

Single Vision $25 copay Up to $30 Bifocal $25 copay Up to $50 Trifocal $25 copay Up to $70 Lenticular $25 copay Up to $70 Progressive - Standard $90 copay Up to $50 Progressive - Premium Tier 1 - 3 $110 - 135 copay Up to $50 Progressive - Premium Tier 4 $90 copay; 20% off retail price less $120 allowance Up to $50

LENS OPTIONS

Anti Reflective Coating - Standard $45 Not covered Anti Reflective Coating - Premium Tier 1 - 2 $57 - 68 Not covered Anti Reflective Coating - Premium Tier 3 20% off retail price Not covered Photochromic - Non-Glass $75 Not covered Polycarbonate - Standard $40 Not covered Scratch Coating - Standard Plastic $15 Not covered Tint - Solid and Gradient $15 Not covered UV Treatment $15 Not covered All Other Lens Options 20% off retail price Not covered

CONTACT LENSES

Contacts - Conventional $0 copay; 15% off balance over

$130 allowance Up to $130

Contacts - Disposable $0 copay; 100% of balance over $130 allowance

Up to $130

Contacts - Medically Necessary $0 copay Up to $210

OTHER

Hearing Care from Amplifon Network Up to 66% off hearing aids; call

1-877-203-0675 Not covered

LASIK or PRK from U.S. Laser Network 15% off retail or 5% off promo price; call 1.800.988.4221

Not covered

FREQUENCY ALLOWED FREQUENCY -

ADULTS

ALLOWED FREQUENCY - KIDS

Exam Once every 12 months from the date of service

Once every 12 months from the date of service

Lenses Once every 12 months from the date of service

Once every 12 months from the date of service

Frame Once every 12 months from the date of service

Once every 12 months from the date of service

Contact Lenses Once every 12 months from the date of service

Once every 12 months from the date of service

(Plan allows the member to receive either contacts and frame, or frame and lens services.)

Fees charged by a Provider for services other than a covered benefit and any local, state or Federal taxes must be paid in full by the Insured Person to the Provider. Such fees, taxes or materials are not covered under the Policy. Allowances provide no remaining balance for future use within the same Benefit Frequency. Some provisions, benefits, exclusions or limitations listed herein may vary by state. No benefits will be paid for services or materials connected with or charges arising from: medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures; Refraction, when not provided as part of a Comprehensive Eye Examination; 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; orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; any Vision Examination or any corrective Vision Materials required by a Policyholder as a condition of employment; safety eyewear; solutions, cleaning products or frame cases; non-prescription sunglasses; plano (non-prescription) lenses; plano (non-prescription) contact lenses; two pair of glasses in lieu of bifocals; electronic vision devices; 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; lost or broken lenses, frames, glasses, or contact lenses that are replaced before the next Benefit Frequency when Vision Materials would next become available. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer. Member receives a 20% discount on items not covered by the plan at In-Network locations. Discount does not apply to Provider's professional services or contact lenses. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see the online provider locator to determine which participating providers have agreed to the discounted rate.

Discounts on vision materials may not be applicable to certain manufacturers' products. The Plan reserves the right to make changes to the products on each tier and to the member out-of-pocket costs. Fixed tier pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels. Services and amounts listed above are subject to change at any time. Discounts are not insured benefits. Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, Policy number VC-19, form number M-9083, or Policy number VC-146, form number M-9184, in New York underwritten by Fidelity Security Life Insurance Company of New York, Policy Number VCN-1, form number MN-1, or Policy Number VCN-19, form number MN-28.

Ready to live your best EyeMed life?

There’s so much more to your vision benefits than copays and coverage. Get ready to see the good stuff for yourself.

Your network is the place to start �See who you want, when you want. You have thousands of providers to choose from — independent eye doctors, your favorite retail stores, even online options.

Keep your eyes open for extra discounts*

�Members already save an average 76% off retail using their EyeMed benefits,1 but our long list of special offers takes benefits even further.

Remember, you’re never alone �We’re always here to help you use your benefits like a pro. Stay in-the-know with text alerts or healthy vision resources from the experts. If it can make benefits easier for you, we do it.

Create a member account at eyemed.com/member Everything is right there in one spot. Check claims and benefits, see special offers, estimate costs and find an eye doctor — search for one with the hours, location and brands you want. For maximum mobility, try the EyeMed App (Google Play or App Store).

PDF-2301-M-651

* Discounts are not insurance. Available at participating providers.

1 �Based on weighted average of sample transactions: EyeMed Insight network/$10 exam copay/$10 materials copay/$150 frame or contact lens allowance. 2021 EyeMed Commercial BOB stats.

This information is available broadly and is not plan or state specific.

THIS PLAN IS NOT MEDICARE SUPPLEMENT. If you are eligible for Medicare, please review “Choosing a Medigap Policy: A Guide to Health Insurance for People With Medicare,” available from the Company.

F I D E L I T Y S E C U R I T Y L I F E I N S U R A N C E C O M P A N Y

3130 Broadway Kansas City, Missouri 64111-2406

Phone 800-648-8624

A STOCK COMPANY

(Herein Called “the Company”)

C-9083VA Exam/Materials

POLICY NUMBER: VC-19

POLICYHOLDER: Gloucester County Public Schools

POLICY EFFECTIVE DATE: October 1, 2016

POLICY ANNIVERSARY DATE: October 1 of the following year and each October 1 thereafter

Fidelity Security Life Insurance Company represents that the Insured Person is insured for the benefits described on the following pages, subject to and in accordance with the terms and conditions of the Policy.

The Policy may be amended, changed, cancelled or discontinued without the consent of any Insured Person.

The Certificate explains the plan of insurance. An individual identification card will be issued to the Insured containing the group number and the Insured’s effective date. The Certificate replaces all certificates previously issued to the Insured under the Policy.

All periods of time under the Policy will begin and end at 12:01 A.M. Local Time at the Policyholder’s business address.

The Policy is issued by Fidelity Security Life Insurance Company at Kansas City, Missouri on the Policy Effective Date.

FIDELITY SECURITY LIFE INSURANCE COMPANY

President Secretary

GROUP VISION INSURANCE CERTIFICATE

THIS IS A LIMITED BENEFIT CERTIFICATE

Please read the Certificate carefully.

TABLE OF CONTENTS

DEFINITIONS

EFFECTIVE DATES

BENEFITS

LIMITATIONS

EXCLUSIONS

TERMINATION OF INSURANCE

CLAIMS

GENERAL PROVISIONS

SCHEDULE OF BENEFITS ............................................................................................................................. Attached (1A)

DEFINITIONS

Benefit Frequency means the period of time in which a benefit is payable as shown in the Schedule of Benefits.

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.

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 or Vision Materials per Benefit Frequency.

Comprehensive Eye 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 cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.

Dependent means any of the following persons whose coverage under the Policy is in force and has not ended:

1. the Insured’s lawful spouse;

2. each unmarried child of the Insured or the Insured’s spouse from birth to age 19;

3. each unmarried child under 25 years of age who is primarily dependent upon the Insured or the Insured’s spouse for support and maintenance;

4. each unmarried child of the Insured or the Insured’s spouse under 25 years of age who is a full-time student; or

5. each unmarried child at least 25 years of age: who is primarily dependent upon the Insured or the Insured’s spouse for support and maintenance because the child is incapable of self-sustaining employment by reason of mental incapacity or physical handicap; who was so incapacitated and is an Insured Person under the Policy on his or her 25 th birthday;

and who has been continuously so incapacitated since his or her 25 th birthday.

Child includes stepchild, foster child, legally adopted child, child legally placed in the Insured’s home for adoption and child under the Insured’s legal guardianship. A full-time student is one who is enrolled at least the minimum number of hours of class a week the school considers as full-time status.

Coverage for a Dependent child who is enrolled as a full-time student and is unable, due to a medical condition, to continue as a full-time student will continue: a) for a period of 12 months from the date the child ceases to be a full-time student; or b) the date the child no longer qualifies as a Dependent, whichever occurs first, provided the child’s treating physician certifies to the Company at the time the child withdraws as a full-time student that the child’s absence is medically necessary.

Formulary means a list, provided by the Company, of Vision Materials covered under the Policy.

Insured means an employee of the Policyholder who meets the eligibility requirements as shown in the Policyholder’s application, and whose coverage under the Policy is in force and has not ended.

Insured Person means the Insured. Insured Person will also include the Insured’s Dependents, if enrolled.

In-Network Provider means a Provider who has signed a Preferred Provider Agreement with the PPO.

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.

Out-of-Network Provider means a Provider, located within the PPO Service Area, who has not signed a Preferred

Provider Agreement with the PPO.

Policy means the Policy issued to the Policyholder.

Policyholder means the Employer named as the Policyholder in the face page of the Policy.

PPO Service Area means the geographical area where the PPO is located.

Preferred Provider Agreement means an agreement between the PPO and a Provider that contains the rates and reimbursement methods for services and supplies provided by such Provider.

Preferred Provider Organization (“PPO”) means a network of Providers and retail chain stores within the PPO Service

Area that has signed a Preferred Provider Agreement.

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

Vision Examination means any eye or visual examination covered under the Policy and shown in the Schedule of

Benefits.

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

EFFECTIVE DATES

Effective Date of Insured’s Insurance. The Insured’s insurance will be effective as follows:

1. if the Policyholder does not require the Insured to contribute toward the premium for this coverage, the Insured’s insurance will be effective on the date the Insured became eligible;

2. if the Policyholder requires the Insured to contribute toward the premium for this coverage, the Insured’s insurance will be effective on the date the Insured became eligible, provided;

a. the Insured has given the Company the Insured’s enrollment form (if required) on, prior to, or within 30 days of the date the Insured became eligible; and

b. the Insured has agreed to pay the required premium contributions; and

3. if the Insured fails to meet the requirements of 2 a) and 2 b) within 30 days after becoming eligible, the Insured’s coverage will not become effective until the Company has verified that the Insured has met these requirements. The

Insured will then be advised of the Insured’s effective date.

Effective Date of Dependents’ Insurance. Coverage for Dependents becomes effective on the later of:

1. the date Dependent coverage is first included in the Insured’s coverage; or

2. the premium due date on or after the date the person first qualifies as the Insured’s Dependent. If an enrollment form is required, the Insured must provide such form and agree to pay any premium contribution that may be required prior to coverage becoming effective.

If the Insured and the Insured’s spouse are both Insureds, one Insured may request to be a Dependent spouse of the other.

A Dependent child may not be covered by more than one Insured.

Newborn Children. A Dependent child born while the Insured’s coverage is in force will be covered from the moment of birth for 31 days or greater, if elected by the Policyholder. In order to continue coverage beyond this period, the Insured must provide notice to the Company and agree to pay any premium contribution that may be required within this period.

Adopted Children. If a Dependent child is placed with the Insured for adoption while the Insured’s coverage is in force, this child will be covered from the date of placement for 31 days or greater, if elected by the Policyholder. In order to continue coverage beyond this period, the Insured must provide notice to the Company and agree to pay any premium contribution that may be required within this period. If proper notice has been given, coverage will continue unless the placement is disrupted prior to legal adoption and the child is removed from placement.

BENEFITS

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

Comprehensive Eye Examination. An Insured Person is eligible for one Comprehensive Eye Examination in each

Benefit Frequency.

In-Network 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 In-Network Provider who will file a claim with the Company.

Out-of-Network Provider Benefits. The Insured Person must pay the Out-of-Network 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 Out-of-Network Provider benefits up to the maximum dollar amount shown in the Schedule of Benefits.

Vision Materials. If 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:

• Lenses provided one time in each Benefit Frequency.

• Frames provided one time in each Benefit Frequency.

• Contact Lenses provided one time in each Benefit Frequency in lieu of lenses.

LIMITATIONS

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.

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; Aniseikonic lenses;

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

3. any 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;

6. non-prescription sunglasses;

7. two pair of glasses in lieu of bifocals;

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

9. 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

10. 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.

TERMINATION OF INSURANCE

The Policyholder or the Company may terminate or cancel the Policy as shown in the Policy.

In the event coverage is terminated due to nonpayment of premium by the Policyholder, the coverage will not be terminated by the Company with respect to Insured Persons, until the Policyholder has been provided written notice of termination, including a specific date, not less than 15 days from the date of such notice, by which coverage will terminate if overdue premium is not paid. Coverage will not terminate for at least 15 days after such notice has been mailed.

For All Insureds. The Insureds’ insurance will cease on the earliest of the following dates:

1. the date the Policy ends;

2. the end of the last period for which any required premium contribution agreed to in writing has been made;

3. the date the Insured is no longer eligible for insurance; or

4. the date the Insured’s employment with the Policyholder ends. The Policyholder may, at the Policyholder’s option, continue insurance for individuals whose employment has ended, if the Policyholder:

a. does so without individual selection between Insureds; and

b. continues to pay any premium contribution for those individuals.

For Dependents. A Dependent’s insurance will cease on the earlier of:

1. the date the Insured’s coverage ends;

2. the date in which the Dependent ceases to be an eligible Dependent as defined in the Policyholder’s application; or

3. the end of the last period for which any required premium contribution has been made.

A Dependent child will not cease to be a Dependent solely because of age if the child is:

1. not capable of self-sustaining employment due to mental incapacity or physical handicap that began before the age limit was reached; and

2. mainly dependent on the Insured for support.

The Company may ask for proof of the eligible Dependent child’s incapacity and dependency two months prior to the date the Dependent child would otherwise cease to be covered.

The Company may require the same proof again, but will not ask for it more than once a year after this coverage has been continued for two years. This continued coverage will end:

1. on the date the Policy ends;

2. on the date the incapacity or dependency ends;

3. on the end of the last period for which any required premium contribution for the Dependent child has been made; or

4. 60 days following the date the Company requests proof and such proof is not provided to the Company.

CLAIMS

Notice of Claim. Written notice of claim must be given to the Company within 30 days after the occurrence or commencement of any loss covered by the Policy, or as soon as is reasonably possible. Notice given by or for the Insured

Person to the Company at the Company’s home office, to the Company’s authorized administrator or to any of the

Company’s authorized agents with sufficient information to identify the Insured Person will be deemed as notice to the

Company.

Claim Forms. The Company will furnish claim forms to the Insured Person within 15 days after notice of claim is received. If the Company does not provide the forms within that time, the Insured Person may send written proof of the occurrence, character and extent of loss for which the claim is made within the time stated in the Policy for filing proof of loss.

Proof of Loss. Written proof of loss must be furnished to the Company at the Company’s home office within 90 days after the date of the loss. Failure to furnish proof within the time required will not invalidate or reduce any claim if it was not reasonably possible to give proof within that time, if the proof is furnished as soon as reasonably possible. In no event, except in the absence of legal capacity, will proof of loss be accepted later than one year from the time proof is required.

Time Payment of Claims. Any benefit payable under the Policy will be paid immediately, but not more than 30 days, upon receipt of due written proof of loss.

Payment of Claims. All claims will be paid to the Insured, unless assigned. Any benefits payable on or after the Insured’s death will be paid to the Insured’s estate.

Right of Recovery. If payment for claims exceeds the amount for which the Insured Person is eligible under any benefit provision or rider of the Policy, the Company has the right to recover the excess of such payment from the Provider or the

Insured.

Legal Actions. No Insured Person can bring an action at law or in equity to recover on the Policy until more than 60 days after the date written proof of loss has been furnished according to the Policy. No such action may be brought after the expiration of three years after the time written proof of loss is required to be furnished. If the time limit of the Policy is less than allowed by the laws of the state where the Insured Person resides, the limit is extended to meet the minimum time allowed by such law.

Claims Experience; Disclosure. The Company, upon request, will provide the Policyholder with a complete record of the Policyholder’s claims experience incurred under the Policy. This record will include all claims incurred for the lesser of: 1) the period of time since the Policy was issued or issued for delivery; or 2) the period of time since the Policy was last renewed, reissued or extended, if already issued. This record will be made available promptly to the Policyholder upon request made but not less than 30 days prior to the date upon which the premiums or contractual terms of the Policy may be amended. Nothing in this provision shall require the disclosure of personal or privileged information about an individual that is protected from disclosure under any applicable federal or state law or regulation.

GENERAL PROVISIONS

Clerical Error. Clerical errors or delays in keeping records for the Policy will not deny insurance that would otherwise have been granted, nor extend insurance that otherwise would have ceased, and call for a fair adjustment of premium and benefits to correct the error.

Conformity to Law. Any provision of the Policy that is in conflict with the laws of the state in which it is issued is amended to conform with the laws of that state.

Entire Contract. The Policy, including any endorsements and riders, the Certificate, the Policyholder’s application, which is attached to the Policy when issued, the Insured’s individual enrollment form, if any, and the eligibility file, if any, are the entire contract between the parties. A copy of the Policy may be examined at the Office of the Policyholder during normal business hours. All statements made by the Policyholder or an Insured will, in the absence of fraud, be deemed representations and not warranties, and no such statement shall be used in defense to a claim hereunder unless it is contained in a written instrument signed by the Policyholder, the Insured, the Insured’s beneficiary or personal representative, a copy of which has been furnished to the Policyholder, the Insured, the Insured’s beneficiary or personal representative.

Amendments and Changes. No agent is authorized to alter or amend the Policy, or to waive any conditions or restrictions herein, or to extend the time for paying any premium. The Policy and the Certificate may be amended at any time by mutual agreement between the Policyholder and the Company without the consent of the Insured, but without prejudice to any loss incurred prior to the effective date of the amendment. No person except an Officer of the Company has authority on behalf of the Company to modify the Policy or to waive or lapse any of the Company’s rights or requirements.

Incontestability. After the Policy has been in force for two years, it can only be contested for nonpayment of premiums.

No statement made by an Insured Person can be used in a contest after the Insured Person’s insurance has been in force for two years during the Insured Person’s lifetime. No statement an Insured Person makes can be used in a contest unless it is in writing and signed by the Insured Person.

Insurance Data. The Policyholder must give the Company the names and ages of all individuals initially insured. The names of persons who later become eligible (whether or not the person becomes insured), and the names of those who cease to be eligible must also be given. The eligibility dates and any other necessary data must be given to the Company so that the premium can be determined.

The Company has the right to audit the Policyholder’s books and records as the books and records relate to this insurance.

The Company may authorize someone else to perform this audit. Any such inspection may be done at any reasonable time.

Workers’ Compensation. The Policy is not a Workers’ Compensation policy. The Policy does not satisfy any requirement for coverage by Workers’ Compensation Insurance.

Physical Examination and Autopsy. The Company, at the Company’s expense, has the right to have the Insured Person examined when and as often as is reasonably necessary while a claim is pending. At the Company’s expense, the

Company may request an autopsy unless prohibited by law.

Gloucester County Public Schools

S-9083(04/12) 1A Exam/Materials

SCHEDULE OF BENEFITS

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 In-Network Out-of-Network Benefit Frequency

VISION EXAMINATION

Comprehensive Eye Examination $10 Co-payment up to $40 12 months

VISION MATERIALS

Standard Plastic Lenses 12 months

Single Vision $25 Co-payment up to $30

Bifocal $25 Co-payment up to $50

Trifocal $25 Co-payment up to $70

Lenticular $25 Co-payment up to $70

Frames $0 Co-payment, up to $130 retail allowance up to $91 12 months

Contact Lenses (only one option available per Benefit Frequency) 12 months

Conventional $0 Co-payment, up to $130 allowance up to $130

Disposable $0 Co-payment, up to $130 allowance up to $130

Medically Necessary Paid in full up to $210

Lens Options 12 months

Standard Progressive Lenses (add on to Bifocal) $90 Co-payment up to $50

Premium Progressive Lenses (add on to Bifocal)

Tier 1 $110 Co-payment up to $50

Tier 2 $120 Co-payment up to $50

Tier 3 $135 Co-payment up to $50

Tier 4 $90 Co-payment, up to $120 allowance up to $50

R-02959VA

F I D E L I T Y S E C U R I T Y L I F E I N S U R A N C E C O M P A N Y

3130 Broadway Kansas City, Missouri 64111-2406

Phone 800-648-8624

AMENDMENT RIDER

For Virginia Residents Only

By attachment of this Rider, the Policy/Certificate is amended by the following:

Any provision of the Policy/Certificate that provides coverage for a Dependent child up to a certain age is amended to cover such child to age 26, regardless of financial dependency, residency, student status, or marital status.

Coverage for a Dependent child who is enrolled as a full-time student and is unable, due to a medical condition, to continue as a full-time student will continue: a) for a period of 12 months from the date the child ceases to be a full-time student; or b) the date the child no longer qualifies as a Dependent, whichever occurs first, provided the child’s treating Physician certifies to the Company at the time the child withdraws as a full-time student that the child’s absence is Medically Necessary. A child’s status as a full-time student will be determined in accordance with the criteria specified by the institution in which the child is enrolled. “Medically Necessary” means the Dependent child’s attending Physician has certified in writing that the Dependent child is unable to attend school on a full-time basis due to an injury or sickness.

This Rider takes effect on the effective date of the Policy/Certificate to which it is attached. This Rider terminates concurrently with the Policy/Certificate to which it is attached. It is subject to all the definitions, limitations, exclusions and conditions of the Policy/Certificate except as stated.

N-00050VA(05/14) 93-21491 Rev 0514

I N S U R A N C E C O M P A N Y

3130 Broadway Kansas City, Missouri 64111-2406

Phone 800-648-8624

COMMONWEALTH OF VIRGINIA

IMPORTANT INFORMATION REGARDING YOUR INSURANCE

In the event you need to contact someone about this insurance for any reason please contact your agent. If no agent was involved in the sale of this insurance, or if you have additional questions you may contact the insurance company issuing this insurance at the following address and telephone number:

Fidelity Security Life Insurance Company

3130 Broadway

P.O. Box 418131

Kansas City, Missouri 64141-8131

(800) 648-8624

If you have been unable to contact or obtain satisfaction from the company or the agent, you may contact the Virginia

State Corporation Commission’s Bureau of Insurance at:

Commonwealth of Virginia

Bureau of Insurance

1300 East Main Street

P.O. Box 1157

Richmond, Virginia 23218

(804) 371-9691 (Local)

(800) 552-7945 (In-state)

(877) 310-6560 (National Toll-free)

Written correspondence is preferable so that a record of your inquiry is maintained. When contacting your agent, company, or the Bureau of Insurance, have your policy number available.

N-00120

I N S U R A N C E C O M P A N Y

3130 Broadway Kansas City, Missouri 64111-2406

Phone 800-648-8624

NOTICE OF ADMINISTRATOR'S CAPACITY

PLEASE READ: This notice advises insured persons of the identity and relationship among the administrator, the policyholder and the insurer:

1. Fidelity Security Life Insurance Company (FSL) has, by agreement, arranged for First American Administrators, Inc.

to provide administrative services for your insurance plan. As administrator, First American Administrators, Inc., is authorized to process claim payments, and perform other services, according to the terms of its agreement with the insurance company. First American Administrators, Inc. is not the insurance company or the policyholder.

2. The policyholder is the entity to whom the insurance policy has been issued. The policyholder is identified on either the face page or schedule page of the policy or certificate.

3. Fidelity Security Life Insurance Company is liable for the funds to pay your insurance claims.

As First American Administrators, Inc. is authorized to process claims for the insurance company, they will do so promptly. In the event there are delays in claims processing, you will have no greater rights to interest or other remedies against First American Administrators, Inc. than would otherwise be afforded to you by law.

N-00211(10/15)

I N S U R A N C E C O M P A N Y

3130 Broadway Kansas City, Missouri 64111-2406

Phone 800-648-8624

CONSUMER NOTICE

Consumer Complaint

If you have a complaint related to quality of care, choice and accessibility of providers, or network adequacy you may contact:

EyeMed Vision Care, LLC Attn: Quality Assurance Department 4000 Luxottica Place Mason, Ohio 45040 or you may call the toll free number at:

1-877-226-1115

If you feel that your complaint has not been satisfactorily resolved you may also contact:

Office of Licensure and Certification (OLC) Virginia Department of Health 9960 Mayland Drive, Suite 401 Henrico, Virginia 23230 Phone Number: 1-804-367-2104 (Ask for MCHIP) Fax Number: 1-804-527-4503 E-mail: mchip@vdh.virginia.gov or

Office of the Managed Care Ombudsman

P.O. Box 1157 Richmond, VA 23218 Or you may call: 1-877-310-6560 In the Richmond metropolitan area call: 804-371-9032 E-mail: ombudsman@scc.virginia.gov

Referral and Authorization Requirements

Any services which cannot be obtained by a Preferred Provider within the PPO Service Area because: 1) due to their specialized nature, there is no Preferred Provider located within the PPO Service Area; 2) are provided by a Provider not in the PPO Service Area; and 3) are specifically authorized in advance by the Covered Person’s Provider and approved by the Company shall be paid in accordance with the Schedule of Benefits, without further deductions, subject to all Policy maximums, limitations, conditions and exclusions, if applicable.

Appeals

The Explanation of Benefits (EOB) explains how to appeal a denied claim. If you appeal a denied claim, you will receive a letter from the EyeMed Quality Assurance Coordinator. If you have questions after receiving this information, you may contact the Quality Assurance Coordinator at EyeMed at:

First American Administrators, Inc.

Attn: Quality Assurance Coordinator 4000 Luxottica Place Mason, Ohio 45040

This letter will acknowledge the member’s request of a review of any adverse claims determination.

If you have any questions regarding an appeal or grievance concerning the services that you have been provided which have not been satisfactorily addressed by your plan, you may contact the Office of the Managed Care Ombudsman for assistance at:

Office of the Managed Care Ombudsman

P.O. Box 1157 Richmond, VA 23218 or you may call: 1-877-310-6560 In the Richmond Metropolitan Area call: 804-371-9032

E-mail: ombudsman@scc.virginia.gov

Provider Directories

You may review an up to date provider list at any time by city, county, state or zip code by visiting the EyeMed website, at www.discovereyemed.com or by contacting the EyeMed customer care center at (866) 939-3633. You may also request a hard copy of the provider directory through the contacts provided above.

Provider Compensation

If you have questions regarding how your eye care provider is compensated please contact EyeMed Provider Relations at:

First American Administrators, Inc.

Attn: Provider Relations 4000 Luxottica Place Mason, Ohio 45040

This plan is subject to regulation by both the State Corporation Commission Bureau of Insurance pursuant to Title 38.2 and the Virginia Department of Health pursuant to Title 32.1.

Emergency Services

Your plan covers Vision Examinations and/or Vision Materials. If you have an after hours emergency for a Covered Benefit, please contact your EyeMed eye care provider the next day. If you have an eye-related emergency, please contact your medical care provider or go to the nearest medical facility.

I N S U R A N C E C O M P A N Y

3130 Broadway Kansas City, Missouri 64111-2406

Phone 800-648-8624

M-9083VA

STATE OF ISSUE: Virginia

Fidelity Security Life Insurance Company agrees to pay the benefits provided by the Policy in accordance with its terms and conditions.

The Policy is issued in consideration of the Policyholder’s application (a copy of which is attached) and receipt by the

Company of the premiums.

All periods of time under the Policy begin and end at 12:01 A.M. Local Time at the Policyholder’s business address.

The Policy may be modified by mutual agreement between the Policyholder and the Company.

The Policy is issued by Fidelity Security Life Insurance Company at Kansas City, Missouri on the Policy Effective Date.

GROUP VISION INSURANCE POLICY

THIS IS A LIMITED BENEFIT POLICY

Please read the Policy carefully.

PREMIUMS

Premiums are payable in advance by the Policyholder. The first premium is due on the effective date of the Policy.

Subsequent premiums are due on the first day of each calendar month thereafter.

The required premium due on each premium due date is the sum of the premiums for all Insureds and their Dependents covered under the Policy. The premiums due will be determined by applying the premium rates then in effect for each plan provided by the Policy to the number of Insured Persons. All premiums are payable to the Company at the

Company’s home office or to any of the Company’s authorized agents.

The premium due may be adjusted due to a change in insurance as requested by the Policyholder or as required by the

Company as follows:

1. if an amount of insurance is added or increased during a calendar month, premiums will be increased as of the date the change becomes effective, unless otherwise mutually agreed;

2. if an amount of insurance is deleted or decreased during a calendar month, premium will cease or be decreased at the end of the calendar month in which the deletion or decrease occurred, unless otherwise mutually agreed;

3. if the Policyholder’s contribution percentage is changed, premium will be adjusted at the end of the calendar month in which the change occurred, unless otherwise mutually agreed; or

4. if the number of eligible employees increases or decreases by more than 10% premium will be adjusted at the end of the calendar month in which the increase or decrease occurred, unless otherwise mutually agreed.

If premiums are due the Company, or premium refunds are due the Policyholder as a result of clerical error or delay in the reporting of dates and/or data to the Company, all premiums or refunds will be calculated at the current rate of premium payment and are limited to a maximum period of three months.

Premium Rate Change. The Company has the right to change the premium rate on any premium due date on or after the fourth Policy Anniversary Date. The Company will provide written notice at least 31 days before the date of change.

Grace Period. A grace period of 31 days will be allowed to the Policyholder for the payment of each premium due after the first premium. The Policy will remain in force during the grace period. If the required premium is not paid by the end of the 31-day period, the Policy will terminate. The Policyholder will be required to pay premium for the grace period.

The Company will mail a notice of termination due to nonpayment of the premium to the Policyholder not less than 15 days prior to the end of the grace period.

Return of Premium. The Company reserves the right to rescind the coverage for one or all Insureds due to misrepresentation or fraud on the Policyholder’s application or an Insured’s enrollment form, if such misrepresentation materially affected the acceptance of the risk.

If, on the date coverage is rescinded, no claims have been paid under the Policy, the Company will return all premiums paid for such coverage to the Policyholder.

If, on the date coverage is rescinded, claims have been paid under the Policy, the Company reserves the right to deduct an amount equal to the amount of such claims paid from the premiums to be returned to the Policyholder.

TERMINATION OF POLICY

The Policyholder or the Company may terminate or cancel the Policy on the earliest of the following:

1. on any date on or after the fourth Policy Anniversary Date. Written notice must be provided to the other party at least

31 days prior to termination;

2. the date the number or percentage of persons covered under the Policy does not meet the minimum participation requirements of 10;

3. the date the required premium has not been paid, except as provided in the Grace Period provision; or

4. the date 100% of the eligible employees are not covered when a contribution is not required by the employee.

The Policyholder is responsible for notifying the Insured of the termination of the Policy.

In the event coverage is terminated due to nonpayment of premium by the Policyholder, the coverage will not be terminated by the Company with respect to Insured Persons, until the Policyholder has been provided written notice of termination, including a specific date, not less than 15 days from the date of such notice, by which coverage will terminate if overdue premium is not paid. Coverage will not terminate for at least 15 days after such notice has been mailed.

CERTIFICATES

The Company will furnish a Certificate to the Policyholder which will set forth the essential features of the insurance coverage.

ADDITIONAL INSUREDS

Insured Persons may be added at any time if they meet the eligibility requirements stated in the Policyholder’s application, complete an enrollment form, if required, and pay any required premium.

INCORPORATION PROVISION

The provisions of the attached Certificate and all Rider(s) issued to amend the Policy after the Policy Effective Date are made a part of the Policy.

THIS PLAN IS NOT MEDICARE SUPPLEMENT. If you are eligible for Medicare, please review “Choosing a Medigap Policy: A Guide to Health Insurance for People With Medicare,” available from the Company.

F I D E L I T Y S E C U R I T Y L I F E I N S U R A N C E C O M P A N Y

3130 Broadway Kansas City, Missouri 64111-2406

Phone 800-648-8624

C-9083VA Exam/Materials

Fidelity Security Life Insurance Company represents that the Insured Person is insured for the benefits described on the following pages, subject to and in accordance with the terms and conditions of the Policy.

The Policy may be amended, changed, cancelled or discontinued without the consent of any Insured Person.

The Certificate explains the plan of insurance. An individual identification card will be issued to the Insured containing the group number and the Insured’s effective date. The Certificate replaces all certificates previously issued to the Insured under the Policy.

All periods of time under the Policy will begin and end at 12:01 A.M. Local Time at the Policyholder’s business address.

The Policy is issued by Fidelity Security Life Insurance Company at Kansas City, Missouri on the Policy Effective Date.

GROUP VISION INSURANCE CERTIFICATE

THIS IS A LIMITED BENEFIT CERTIFICATE

Please read the Certificate carefully.

TABLE OF CONTENTS

DEFINITIONS

EFFECTIVE DATES

BENEFITS

LIMITATIONS

EXCLUSIONS

TERMINATION OF INSURANCE

CLAIMS

GENERAL PROVISIONS

SCHEDULE OF BENEFITS ............................................................................................................................. Attached (1A)

DEFINITIONS

Benefit Frequency means the period of time in which a benefit is payable as shown in the Schedule of Benefits.

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.

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 or Vision Materials per Benefit Frequency.

Comprehensive Eye 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 cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.

Dependent means any of the following persons whose coverage under the Policy is in force and has not ended:

1. the Insured’s lawful spouse;

2. each unmarried child of the Insured or the Insured’s spouse from birth to age 19;

3. each unmarried child under 25 years of age who is primarily dependent upon the Insured or the Insured’s spouse for support and maintenance;

4. each unmarried child of the Insured or the Insured’s spouse under 25 years of age who is a full-time student; or

5. each unmarried child at least 25 years of age: who is primarily dependent upon the Insured or the Insured’s spouse for support and maintenance because the child is incapable of self-sustaining employment by reason of mental incapacity or physical handicap; who was so incapacitated and is an Insured Person under the Policy on his or her 25 th birthday;

and who has been continuously so incapacitated since his or her 25 th birthday.

Child includes stepchild, foster child, legally adopted child, child legally placed in the Insured’s home for adoption and child under the Insured’s legal guardianship. A full-time student is one who is enrolled at least the minimum number of hours of class a week the school considers as full-time status.

Coverage for a Dependent child who is enrolled as a full-time student and is unable, due to a medical condition, to continue as a full-time student will continue: a) for a period of 12 months from the date the child ceases to be a full-time student; or b) the date the child no longer qualifies as a Dependent, whichever occurs first, provided the child’s treating physician certifies to the Company at the time the child withdraws as a full-time student that the child’s absence is medically necessary.

Formulary means a list, provided by the Company, of Vision Materials covered under the Policy.

Insured means an employee of the Policyholder who meets the eligibility requirements as shown in the Policyholder’s application, and whose coverage under the Policy is in force and has not ended.

Insured Person means the Insured. Insured Person will also include the Insured’s Dependents, if enrolled.

In-Network Provider means a Provider who has signed a Preferred Provider Agreement with the PPO.

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.

Out-of-Network Provider means a Provider, located within the PPO Service Area, who has not signed a Preferred

Provider Agreement with the PPO.

Policy means the Policy issued to the Policyholder.

Policyholder means the Employer named as the Policyholder in the face page of the Policy.

PPO Service Area means the geographical area where the PPO is located.

Preferred Provider Agreement means an agreement between the PPO and a Provider that contains the rates and reimbursement methods for services and supplies provided by such Provider.

Preferred Provider Organization (“PPO”) means a network of Providers and retail chain stores within the PPO Service

Area that has signed a Preferred Provider Agreement.

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

Vision Examination means any eye or visual examination covered under the Policy and shown in the Schedule of

Benefits.

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

EFFECTIVE DATES

Effective Date of Insured’s Insurance. The Insured’s insurance will be effective as follows:

1. if the Policyholder does not require the Insured to contribute toward the premium for this coverage, the…