Atch2_EvidenceofCoverage.pdf

Group Vision Care Policy

Vision Care for Life

Group Name: CONSUMER FINANCIAL PROTECTION BUREAU Group Number: 30025240 Effective Date: JULY 17, 2011

Evidence of Coverage

Provided by:

VISION SERVICE PLAN INSURANCE COMPANY

3333 Quality Drive, Rancho Cordova, CA 95670

(916) 851-5000 (800) 877-7195

REG-EOC-DC-1199 07/01/11 Clb

To be filled in by employer in the event this document is used to develop a Summary Plan Description:

NAME OF EMPLOYER:

NAME OF PLAN:

PRINCIPAL ADDRESS:

EMPLOYER I.D.#:

POLICY #:

PLAN ADMINISTRATOR:

ADDRESS:

PHONE NUMBER:

REGISTERED AGENT FOR SERVICE OF LEGAL PROCESS, IF DIFFERENT FROM PLAN ADMINISTRATOR:

ADDRESS:

This form is a summary of the Policy provisions and is presented as a matter of general information only. It is not a substitute for the provisions of the Policy itself. A copy of the Policy will be furnished on request.

DEFINITIONS:

ADDITIONAL BENEFIT

RIDER

The document attached to this Evidence of Coverage, when purchased by Group, which lists selected vision care services and vision care materials that a Covered Person is entitled to receive by virtue of the Policy.

BENEFIT AUTHORIZATION Authorization issued by VSP identifying the individual named as a Covered Person of VSP, and identifying those Plan Benefits to which a Covered Person is entitled.

COPAYMENTS Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits which are not fully covered.

COVERED PERSON An Enrollee or Eligible Dependent who meets VSP’s eligibility criteria and on whose behalf Premiums have been paid to VSP, and who is covered under the Policy.

ELIGIBLE DEPENDENT Any legal dependent of an Enrollee of Group who meets the criteria established by Group and approved by VSP under section VI. ELIGIBILITY FOR COVERAGE of the Policy under which such Enrollee is covered.

EMERGENCY CONDITION A condition, with sudden onset and acute symptoms, that requires the Covered Person to obtain immediate medical care, or an unforeseen occurrence requiring immediate, non-medical action.

ENROLLEE An employee or member of Group who meets the criteria for eligibility specified under section VI.

ELIGIBILITY FOR COVERAGE of the Policy.

EXPERIMENTAL NATURE Procedure or lens that is not used universally or accepted by the vision care profession, as determined by VSP.

GROUP An employer or other entity which contracts with VSP for coverage under this Policy in order to provide vision care coverage to its Enrollees and their Eligible Dependents.

MEMBER DOCTOR An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision care materials on behalf of Covered Persons of VSP.

NON-MEMBER PROVIDER Any optometrist, optician, ophthalmologist, or other licensed and qualified vision care provider who has not contracted with VSP to provide vision care services and/or vision care materials to Covered Persons of VSP.

PLAN BENEFITS The vision care services and vision care materials which a Covered Person is entitled to receive by virtue of coverage under the Policy, as defined on the enclosed insert or in the Schedule of Benefits attached as Exhibit A to the Group Policy maintained by your Group Administrator.

PREMIUMS The payments made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits, as stated in the Schedule of Premiums attached as Exhibit B to the Group Policy document maintained by your Group Administrator.

RENEWAL DATE The date on which the Policy shall renew or terminate if proper notice is given.

SCHEDULE OF BENEFITS The document, attached as Exhibit A to the Group Policy document maintained by your Group

Administrator, which lists the vision care services and vision care materials which a Covered Person is entitled to receive by virtue of the Policy.

SCHEDULE OF PREMIUMS The document, attached as Exhibit B to the Group Policy document maintained by your Group

Administrator, which states the payments to be made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits.

ELIGIBILITY FOR COVERAGE

Enrollees: To be covered, a person must currently be an employee or member of the Group, and meet the established coverage criteria mutually agreed upon by Group and VSP.

Eligible Dependents: If dependent coverage is provided, the persons eligible shall include the legal spouse/domestic partner of any Enrollee, and any unmarried child of an Enrollee who has not reached the limiting age as shown on the enclosed insert, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.

A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self-sustaining employment because of mental or physical disability, and chiefly dependent upon the Enrollee for support and maintenance.

PREMIUMS

Your Group is responsible for payments of the periodic charges for your coverage. Your Group will notify you of your share of the charges, if any.

The entire cost of the program is paid to VSP by your Group.

PROCEDURES FOR USING THE POLICY

1. When you want to receive Plan Benefits, contact VSP or a Member Doctor. A list of names, addresses, and phone numbers of Member

Doctors in your area can be obtained from your Group, Plan Administrator, or VSP. If this list does not cover the area in which you wish to seek services, call or write the VSP office nearest you to find one that does.

2. If you are eligible for Plan Benefits, VSP will provide Benefit Authorization directly to the Member Doctor. If you contact a Member Doctor directly, you must identify yourself as a VSP member so the doctor can obtain Benefit Authorization from VSP.

3. When such Benefit Authorization is provided by VSP, and services are performed prior to the expiration date of the Benefit Authorization, this will constitute a claim against the Policy in spite of your termination of coverage or the termination of the Policy. Should you receive services from a Member Doctor without such Benefit Authorization or obtain services from a Non-Member Doctor, you are responsible for payment in full to the provider.

4. You pay only the Copayment (if any) to a Member Doctor for services under this Policy. VSP will pay the Member Doctor directly according to its agreement with the doctor.

Note: If you are eligible for and obtain Plan Benefits from a Non-Member Provider, you should pay the provider his/her full fee. You will be reimbursed by VSP in accordance with the Non-Member Provider reimbursement schedule shown on the enclosed insert, less any applicable Copayments.

5. In emergency conditions, when immediate vision care of a medical nature such as for bodily trauma or disease is necessary, Covered Person can obtain covered services by contacting a Member Doctor (or Out-of-Network Provider if the attached Schedule of Benefits indicates Covered Person’s Plan includes such coverage). No prior approval from VSP is required for Covered Person to obtain vision care for Emergency Conditions of a medical nature. However, services for medical conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Primary EyeCare Plans. If coverage for one of these plans is not indicated on the attached Schedule of Benefits or Addendum, Covered Person is not covered by VSP for medical services and should contact a physician under Covered Person’s medical insurance plan for care. For emergency conditions of a non-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP’s Customer Service Department for assistance.

Emergency vision care is subject to the same benefit frequencies, plan allowances, Copayments and exclusions stated herein. Reimbursement to Member Doctors will be made in accordance with their agreement with VSP.

6. In the event of termination of a Member Doctor’s membership in VSP, VSP will be liable to the Member Doctor for services rendered to you at the time of termination and permit Member Doctor to continue to provide you with Plan Benefits until the services are completed or until VSP makes reasonable and appropriate arrangements for the provision of such services by another Member Doctor.

BENEFIT AUTHORIZATION PROCESS

VSP authorizes Plan Benefits according to the latest eligibility information furnished to VSP by Covered Person's Group and the level of coverage (i.e. service frequencies, covered materials, reimbursement amounts, limitations, and exclusions) purchased for Covered Person by Group under this Policy. When Covered Person requests services under this Policy, Covered Person's prior utilization of Plan Benefits will be reviewed by VSP to determine if Covered Person is eligible for new services based upon Covered Person's Policy’s level of coverage. Please refer to the attached Schedule of Benefits for a summary of the level of coverage provided to Covered Person by Group.

BENEFITS AND COVERAGES

Through its Member Doctors, VSP provides Plan Benefits to Covered Persons, subject to the limitations, exclusions, and Copayment(s) described herein. When you wish to obtain Plan Benefits from a Member Doctor, you should contact the Member Doctor of your choice, identify yourself as a VSP member, and schedule an appointment. If you are eligible for Plan Benefits, VSP will provide Benefit Authorization for you directly to the Member Doctor prior to your appointment.

1. Eye Examination: A complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of corrective eyewear where indicated.

2. Lenses: The Member Doctor will order the proper lenses necessary for your visual welfare. The doctor shall verify the accuracy of the finished lenses.

3. Frames: The Member Doctor will assist in the selection of frames, properly fit and adjust the frames, and provide subsequent adjustments to frames to maintain comfort and efficiency.

4. Contact lenses: Unless otherwise indicated on the enclosed insert, contact lenses are available under this Plan in lieu of all other lens and frame benefits described herein for the current eligibility period.

Necessary contact lenses, together with professional services, will be provided as indicated on the enclosed insert.

When Elective contact lenses are obtained from a Member Doctor, VSP will provide an allowance toward the cost of professional fees and materials as shown on the enclosed insert. A 15% discount shall also be applied to the Member Doctor’s usual and customary professional fees for contact lens evaluation and fitting. Contact lens materials are provided at the Member Doctor’s usual and customary charges.

5. If you elect to receive vision care services from a Member Doctor, Plan Benefits are provided subject only to your payment of any applicable Copayment. If your Plan includes Non-Member Provider coverage, and you choose to obtain Plan Benefits from a Non-Member Provider, you should pay the Non-Member Provider his/her full fee. VSP will reimburse you in accordance with the reimbursement schedule shown on the enclosed insert, less any applicable Copayment. THERE IS NO ASSURANCE THAT THE SCHEDULE WILL BE SUFFICIENT TO PAY FOR THE EXAMINATION OR THE MATERIALS. Availability of services under the Non-Member Provider reimbursement schedule is subject to the same time limits and Copayments as those described for Member Doctor services. Services obtained from a Non-Member Provider are in lieu of obtaining services from a Member Doctor and count toward plan benefit frequencies.

6. Low Vision Services and Materials (applicable only if included in your Plan Benefits outlined on the enclosed insert): The Low Vision Benefit provides special aid for people who have acuity or visual field loss that cannot be corrected with regular lenses. If a Covered Person falls within this category, he or she will be entitled to professional services as well as ophthalmic materials, including but not limited to, supplemental testing, evaluations, visual training, low vision prescription services, plus optical and non-optical aids, subject to the frequency and benefit limitations as outlined on the enclosed insert. Consult your Member Doctor for details.

COPAYMENT

The benefits described herein are available to you subject only to your payment of any applicable Copayment(s) as described in this booklet and on the enclosed insert. ANY ADDITIONAL CARE, SERVICE AND/OR MATERIALS NOT COVERED BY THIS PLAN MAY BE ARRANGED BETWEEN

YOU AND THE DOCTOR.

EXCLUSIONS AND LIMITATIONS OF BENEFITS

Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by calling VSP’s Customer Care Division at (800) 877-7195.

This vision service plan is designed to cover visual needs rather than cosmetic materials. If you select any of the following options, the Plan will pay the basic cost of the allowed lenses or frames, and you will be responsible for the option's extra cost, unless it is defined as a Plan Benefit in the Schedule of Benefits attached as Exhibit A to the Group Policy maintained by your Group Administrator.

• Optional cosmetic processes.

• Anti-reflective coating.

• Color coating.

• Mirror coating.

• Cosmetic lenses.

• Laminated lenses.

• Oversize lenses.

• Polycarbonate lenses.

• Photochromic lenses, tinted lenses except Pink #1 and Pink #2.

• Certain limitations on low vision care.

NOT COVERED

There is no benefit under this plan for professional services or materials connected with:

1. Orthoptics or vision training and any associated supplemental testing; plano lenses (less than ±.50 diopter power); or two pair of glasses in lieu of bifocals.

2. Replacement of lenses and frames furnished under this plan which are lost or broken except at the normal intervals when services are otherwise available.

3. Medical or surgical treatment of the eyes.

4. Corrective vision treatment of an Experimental Nature.

5. Costs for services and/or materials above Plan Benefit allowances indicated on the enclosed insert.

6. Services/materials not indicated as covered Plan Benefits on the enclosed insert.

LIABILITY IN EVENT OF NON-PAYMENT

IN THE EVENT VSP FAILS TO PAY THE PROVIDER, YOU SHALL NOT BE LIABLE FOR ANY SUMS OWED BY VSP OTHER THAN THOSE NOT

COVERED BY THE POLICY.

COMPLAINTS AND GRIEVANCES

If Covered Person ever has a question or problem, Covered Person’s first step is to call VSP’s Customer Service Department. The Customer Service Department will make every effort to answer Covered Person’s question and/or resolve the matter informally. If a matter is not initially resolved to the satisfaction of a Covered Person, the Covered Person may communicate a complaint or grievance to VSP orally or in writing by using the complaint form that may be obtained upon request from the Customer Service Department. Complaints and grievances include disagreements regarding access to care, or the quality of care, treatment or service. Covered Persons also have the right to submit written comments or supporting documentation concerning a complaint or grievance to assist in VSP’s review. VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special circumstances require an extension of time. In that case, resolution shall be achieved as soon as possible, but no later than one hundred twenty (120) days after VSP’s receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved within thirty

(30) days, a letter will be sent to the Covered Person to indicate VSP’s expected resolution date. Upon final resolution, the Covered Person will be notified of the outcome in writing.

Claim Payments and Denials A. Initial Determination: VSP will pay or deny claims within thirty (30) calendar days of the receipt of the claim from the Covered Person or Covered Person’s authorized representative. In the event that a claim cannot be resolved within the time indicated VSP may, if necessary, extend the time for decision by no more than fifteen (15) calendar days.

B. Request for Appeals: If a Covered Person’s claim for benefits is denied by VSP in whole or in part, VSP will notify the Covered Person in writing of the reason or reasons for the denial. Within one hundred eighty (180) days after receipt of such notice of denial of a claim, Covered Person may make a verbal or written request to VSP for a full review of such denial. The request should contain sufficient information to identify the Covered Person for whom a claim for benefits was denied, including the name of the VSP Enrollee, Member Identification Number of the VSP Enrollee, the Covered Person’s name and date of birth, the name of the provider of services and the claim number. The Covered Person may state the reasons the Covered Person believes that the claim denial was in error. The Covered Person may also provide any pertinent documents to be reviewed. VSP will review the claim and give the Covered Person the opportunity to review pertinent documents, submit any statements, documents, or written arguments in support of the claim, and appear personally to present materials or arguments. Covered Person or Covered Person’s authorized representative should submit all requests for appeals to:

VSP

Member Appeals

3333 Quality Drive Rancho Cordova, CA 95670

(800) 877-7195

VSP’s determination, including specific reasons for the decision, shall be provided and communicated to the Covered Person within thirty (30) calendar days after receipt of a request for appeal from the Covered Person or Covered Person’s authorized representative.

If Covered Person disagrees with VSP’s determination, he/she may request a second level appeal within sixty (60) calendar days from the date of the determination. VSP shall resolve any second level appeal within thirty (30) calendar days.

When Covered Person has completed all appeals mandated by the Employee Retirement Income Security Act of 1974 (“ERISA”), additional voluntary alternative dispute resolution options may be available, including mediation and arbitration. Covered Person should contact the U. S.

Department of Labor or the State insurance regulatory agency for details. Additionally, under ERISA (Section 502(a)(1)(B)) [29 U.S.C.

1132(a)(1)(B)], Covered Person has the right to bring a civil (court) action when all available levels of reviews of denied claims, including the appeal process, have been completed, the claims were not approved in whole or in part, and Covered Person disagrees with the outcome.

TERMINATION OF BENEFITS

Cancellation conditions of your vision care Policy are shown on the enclosed insert. Plan Benefits will cease on the date of cancellation of this Policy whether the cancellation is by your Group or by VSP due to non-payment of Premium. If you are receiving service as of the termination date of the Policy, such service shall be continued to completion, but in no event beyond six (6) months after the termination date of the Policy.

INDIVIDUAL CONTINUATION OF BENEFITS

This program is available to groups of a minimum of ten (10) employees and is, therefore, not available on an individual basis. When a Group terminates its coverage, individual coverage is not available for Enrollees who may desire to retain same.

3333 Quality Drive

Rancho Cordova, CA 95670 Group Name: CONSUMER FINANCIAL PROTECTION BUREAU

Plan Number: 30025240

Effective Date: JULY 17, 2011

Plan Term: FIFTY-FOUR (54) MONTHS

VISION CARE PLAN

DISCLOSURE FORM AND EVIDENCE OF COVERAGE

PLAN ADMINISTRATOR: Nikki DiPalma

(Name)

1801 L St NW

(Address)

Washington, DC 20036-5104

(City, State, Zip)

MONTHLY PREMIUM: YOUR GROUP IS RESPONSIBLE FOR PAYMENT TO VISION SERVICE

PLAN OF THE PERIODIC CHARGES FOR YOUR COVERAGE. YOU WILL

BE NOTIFIED OF YOUR SHARE OF THE CHARGES, IF ANY, BY YOUR

GROUP.

ELIGIBILITY: ENROLLEES & ELIGIBLE DEPENDENTS: UNMARRIED DEPENDENT

CHILDREN ARE COVERED TO AGE 22 OR AGE 25 IF FULL-TIME

STUDENTS. THE WAITING PERIOD IS THE SAME AS YOUR OTHER

6 7

HEALTH BENEFITS.

PLAN AND SCHEDULE: VSP CHOICE PLAN

EXAMINATION: ONCE EVERY PLAN YEAR*

LENSES: ONCE EVERY PLAN YEAR*

FRAMES: ONCE EVERY PLAN YEAR*

*PLAN YEAR BEGINS JULY 17, 2011, EACH JANUARY 1ST THEREAFTERE THROUGH DECEMBER 31, 2015.

TERM, TERMINATION AND RENEWAL: AFTER THE POLICY TERM, THIS POLICY WILL CONTINUE ON A MONTH

TO MONTH BASIS OR UNTIL TERMINATED BY EITHER PARTY GIVING THE

OTHER SIXTY (60) DAYS PRIOR WRITTEN NOTICE.

TYPE OF ADMINISTRATION: BENEFITS ARE FURNISHED UNDER A VISION CARE PLAN PURCHASED

BY THE GROUP AND PROVIDED BY VISION SERVICE PLAN (VSP)

UNDER WHICH VSP IS FINANCIALLY RESPONSIBLE FOR THE PAYMENT

OF CLAIMS.

VSP'S ADDRESS IS: VISION SERVICE PLAN

3333 QUALITY DRIVE

RANCHO CORDOVA, CA 95670

SCHEDULE OF BENEFITS

GENERAL

This Schedule and any Additional Benefit Rider(s), when purchased by Group, attached hereto list the vision care services and vision care materials to which Covered Persons of VSP are entitled, subject to any Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Non-Member Provider services as indicated by the reimbursement provisions below, vision care services and vision care materials may be received from any licensed optometrist, ophthalmologist, or dispensing optician, whether Member Doctors or Non-Member Providers.

Member Doctors are those doctors who have agreed to participate in VSP’s Choice Network.

When Plan Benefits are received from Member Doctors, benefits appearing in the first column below are applicable subject to any Copayment(s) as stated below. When Plan Benefits are available and received from Non-Member Providers, you are reimbursed for such benefits according to the schedule in the second column below less any applicable Copayment.

PLAN BENEFITS MEMBER DOCTOR BENEFIT NON-MEMBER PROVIDER BENEFIT

VISION CARE SERVICES

Vision Examination Covered in Full* Up to $ 60.00*

VISION CARE MATERIALS

Lenses

Single Vision Covered in Full* Up to $ 61.00* Bifocal Covered in Full* Up to $ 84.00* Trifocal Covered in Full* Up to $ 100.00* Lenticular Covered in Full* Up to $ 134.00*

Frames Covered up to $200 Plan Allowance* Up to $ 75.00*

CONTACT LENSES

Necessary Professional Fees and Materials Covered in Full* Up to $ 220.00*

Elective

Professional Fees** and Materials Up to $ 160.00 Up to $ 88.00

Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Member Doctor or Non-Member Provider. Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses.

LENS OPTIONS

Scratch coating Covered in full Not Covered Blended lenses Covered in full Up to $ 84.00 Progressive lenses Covered in full Up to $ 84.00 UV (ultraviolet) protected Covered in full Not Covered

*Subject to Copayment, if any.

**15% discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation and fitting.

There shall be no Copayment for the examination. If materials (lenses and frames) are provided, there shall be a Copayment of $ 20.00 payable by the Covered Person to the Member Doctor at the time the materials are ordered. The Copayment shall not apply to Elective Contact Lenses.

LOW VISION

Professional services for severe visual problems not corrected with regular lenses, including:

Supplemental Testing Covered in Full Up to $125.00 (includes evaluation, diagnosis and prescription of vision aids where indicated)

Supplemental Aids 75% of cost 75% of cost

Maximum allowable for all Low Vision benefits of $1000.00 every two (2) years.

THIS EVIDENCE OF COVERAGE CONSTITUTES ONLY A SUMMARY OF THE VISION PLAN. THE VISION PLAN DOCUMENT MUST BE

CONSULTED TO DETERMINE THE EXACT TERMS AND CONDITIONS OF COVERAGE.

PLAN BENEFITS

AFFILIATE PROVIDERS

GENERAL

Affiliate Providers are providers of Covered Services and Materials who are not contracted as Member Doctors but who have agreed to bill VSP directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers may be unable to provide all Plan Benefits included in this Schedule. Covered Persons should discuss requested services with their provider or contact VSP Customer Care for details.

COPAYMENT

There shall be a total Copayment of $ 20.00 for the examination and materials payable by the Covered Person at the time services are rendered. The Copayment shall not apply to Elective Contact Lenses.

COVERED SERVICES AND MATERIALS

EYE EXAMINATION- Covered in full* once every 12 months**

Comprehensive examination of visual functions and prescription of corrective eyewear.

LENSES - Covered in full* once every 12 months** Spectacle Lenses (Single, Lined Bifocal, Progressive, or Lined Trifocal )

Polycarbonate lenses are covered in full for dependent children up to age 22.

FRAMES - Covered up to the $110 Plan allowance* once every 12 months**

CONTACT LENSES

ELECTIVE

Elective Contact Lenses are covered up to $ 160.00 once every 12 months**

The Elective Contact Lens allowance applies to materials only.

NECESSARY

Necessary Contact Lenses are covered up to $ 220.00* once every 12 months**

Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.

Contact Lenses are provided in place of spectacle lens and frame benefits available herein.

*Less any applicable Copayment.

**beginning with the first day of the Benefit Period.

LOW VISION

Professional services for severe visual problems not correctable with regular lenses, including:

Supplemental Testing: Up to $ 125.00† -Includes evaluation, diagnosis and prescription of vision aids where indicated.

Supplemental Aids: 75% of Affiliate Provider’s fee up to $1000.00†

†Maximum benefit for all Low Vision services and materials is $1000.00 every two (2) years and a maximum of two supplemental tests within a two-year period

Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.

EXCLUSIONS AND LIMITATIONS OF BENEFITS

1. Exclusions and limitations of benefits described above for Member Doctors shall also apply to services rendered by

Affiliate Providers.

2. Services from an Affiliate Provider are in lieu of services from a Member Doctor or a Non-Member Provider.

3. VSP is unable to require Affiliate Providers to adhere to VSP’s quality standards.

4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a membership in such entities as a condition of obtaining Plan Benefits.

ADDENDUM

ADDITIONAL BENEFIT - COMPUTER VISIONCARE PLAN

CHOICE NETWORK

GENERAL

This Rider lists the vision care benefits to which Covered Persons of VSP are entitled, subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein. This Rider forms a part of the Policy or Evidence of Coverage to which it is attached.

COVERED PERSONS WHO MEET THE ELIGIBILITY REQUIREMENTS OUTLINED BELOW AND WHO UTILIZE A

COMPUTER MONITOR SHALL BE ELIGIBLE FOR THE COMPUTER VISIONCARE (CVC) PLAN.

BENEFIT PERIOD

A period beginning on July17, 2011 and ending on December 31, 2011.

Continueing a twelve month period beginning on January 1st and ending on December 31st

ELIGIBILITY

The following are Covered Persons under this Policy.

• Enrollee.

See schedule below for Plan Benefits, payments and/or reimbursement subject to any Copayment(s) as stated:

The benefits herein are available to each Covered Person subject only to payment of the applicable Copayment by the Covered Person. Plan Benefits received from Member Doctors and Non-Member Providers require Copayments. Covered Persons must also follow Benefit Authorization procedures.

There are no Copayments for this coverage.

PLAN BENEFITS

SERVICE OR MATERIAL

MEMBER DOCTOR

BENEFIT

FREQUENCY

Eye Examination

Covered in full*

Available once each 12 months**

A Limited Level supplemental vision analysis of the eyes and related structures that addresses the specific visual needs of computer use.

**Beginning with the first day of the Benefit Period.

Lenses

Single Vision Covered in full *

Bifocal

Covered in full *

Trifocal

Near Variable Focus Covered in full *

Occupational Progressive

Available only when the Covered Person has been diagnosed by an eye care professional as having a vision condition affecting computer use.

Frames Covered up to the $90

Plan Allowance*

VSP reserves the right to limit the cost of the frames provided by Member Doctors under this Plan. The current allowance shall be published periodically by VSP to its Member Doctors and will be set at a level to cover a sufficient number of frames in common use.

*Less any applicable Copayment.

**Beginning with the first day of the Benefit Period.

ASSOCIATED VISION THERAPY

Specific to computer use $ 200.00 per year Available once each 12 months**

This benefit is limited to Covered Persons who are eligible for CVC Coverage and who are diagnosed as having one of the following conditions:

Accommodative Infacility – The inability (or inefficiency) to change focus quickly when looking from one distance to another or the inability to maintain focus at one distance for a prolonged period of time.

(Primarily when looking at things up close.)

Convergence Insufficiency – The occasional problem with the eye muscles’ ability to point the eyes straight when working up close.

EXCLUSIONS AND LIMITATIONS OF BENEFITS

CVC VISIONCARE PLAN

PATIENT OPTIONS

Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by calling VSP’s Customer Care Division at (800) 877-7195.

This vision service plan is designed to cover visual needs rather than cosmetic materials. When a Covered Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the additional costs for the options.

• Optional cosmetic processes.

• Anti-reflective coating.

• Color coating.

• Mirror coating.

• Scratch coating.

• Blended lenses.

• Cosmetic lenses.

• Laminated lenses.

• Oversize lenses.

• Polycarbonate lenses.

• Progressive multifocal lenses.

• Photochromic lenses, tinted lenses except Pink #1 and Pink #2.

• UV (ultraviolet) protected lenses.

• Certain limitations on low vision care.

NOT COVERED

There are no benefits for professional services or materials connected with:

• Subnormal vision aids.

• Orthoptics or vision training and any associated supplementary testing not specifically related to working with a computer.

• Plano lenses.

• Two pair of glasses in lieu of bifocals.

• Contact lenses.

• Photochromic or tints greater than 20%.

• Laminated lenses.

• Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when services are otherwise available.

• Medical or surgical treatment of the eyes.

• Corrective vision treatment of an Experimental Nature.

• Services or materials of a cosmetic nature.

• Services and/or materials not indicated on this Rider as covered Plan Benefits.

SERVICES FROM NON-MEMBER PROVIDERS

LIABILITY OF COVERED PERSONS FOR PAYMENT

REIMBURSEMENT PROVISIONS

When a Covered Person chooses to receive services from a Non-Member Provider, services may be secured from any optometrist, ophthalmologist and/or dispensing optician. This Plan then becomes an indemnity plan reimbursing according to a schedule of allowances. The Covered Person should pay the Provider’s fee in full. VSP will reimburse the Covered Person in accordance with the following schedule.

THERE IS NO ASSURANCE THAT THE AMOUNT REIMBURSED WILL BE SUFFICIENT TO PAY FOR THE

EXAMINATION OR THE MATERIALS IN FULL.

AVAILABILITY OF SERVICES UNDER THIS REIMBURSEMENT SCHEDULE IS SUBJECT TO THE SAME TIME LIMITS AND COPAYMENT AS THOSE DESCRIBED FOR MEMBER DOCTORS. SERVICES OBTAINED FROM NON-MEMBER

PROVIDERS ARE IN LIEU OF SERVICES FROM A MEMBER DOCTOR.

VSP IS UNABLE TO REQUIRE NON-MEMBER PROVIDERS TO ADHERE TO VSP’S QUALITY STANDARDS.