RFP_31786-00192_Appendix_7.11_Basic_Plan_Certificate_Eff.%201-1-26_.docx

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® 2600 Grand Blvd., Suite 900 Kansas City, Missouri 64108-4626 Phone 800-648-8624

A STOCK COMPANY

(Herein Called “the Company”)

POLICY NUMBER: VC-146

POLICYHOLDER: State of Tennessee

Fidelity Security Life Insurance Company represents that the Member is insured for the benefits described in 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 Member.

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

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.

Revised: 01/01/2026 Basic Plan

C-9203TN(01/26)

Exam/Materials

TABLE OF CONTENTS

C-9203TN(01/26)

DEFINITIONS

Agency Benefits Coordinator (ABC) means a designated and trained employee of the Employer who assists BA to facilitate enrollment, terminations, and guidance to Members related to the vision benefits.

Allowance means the benefit amount shown in the Schedule of Benefits that is the maximum amount payable by the Company, subject to the expenses incurred. The Member is responsible for any amounts due above the Allowance. The Allowance cannot be used to satisfy a Copayment.

Annual Enrollment means a period designated by BA within the current Plan Year during which eligible Employees or Retirees may make coverage elections for the upcoming Plan Year.

Benefits Administration (BA) means a division of the Department of Finance and Administration which performs administrative functions for the State, Local Education, and Local Government Insurance Committees and for the Vision Plan.

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 January 1. Each new Benefit Frequency begins at the expiration of the previous Benefit Frequency.

Consolidated Omnibus Budget Reconciliation Act (COBRA) means the federal law that allows Employees, Spouses, and Dependents to extend their insurance for a specified length of time after losing coverage if certain conditions are satisfied.

Copayment or Copay means the designated amount, if any, shown in the Schedule of Benefits each Member must pay to a Provider before benefits are payable for a covered Vision Examination or Vision Materials per Benefit Frequency.

Company means Fidelity Security Life Insurance Company.

Comprehensive Eye Examination means a general evaluation of the complete visual system. The examination includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields, basic sensorimotor examination and Refraction. It always includes initiation of diagnostic and treatment programs. It may include biomicroscopy, examination with cycloplegia or mydriasis and tonometry, as determined by the Provider. These services may be performed at different sessions but comprise only one Comprehensive Eye Examination.

Dependent means an individual who meets the following eligibility criteria based upon an Employee or Retiree’s eligibility. An individual cannot enroll as an Employee and as a Dependent under the same group plan (state, local education, or local government.) If both parents of a child qualify as eligible Employees, only one Employee (parent) can enroll Dependent children.

1. A legally married spouse;

2. A child under the age of 26 who meets at least one of the following criteria without consideration of factors such as financial dependency, marital status, enrollment in school, or residency:

a. Subscriber’s natural (biological) child,

b. Subscriber’s adopted child (including a child placed for adoption in anticipation of adoption);

3. A Subscriber’s or spouse’s stepchild under the age of 26;

4. A person under age 26 who is placed with the Subscriber by a valid order of guardianship, custody, or conservatorship (or legally equivalent order) by a court of competent jurisdiction ("placement order") as provided below:

a. The Subscriber must provide certification upon enrollment and upon request that: the placement order is in effect and has not expired by subsequent court order or by operation of law, and the Subscriber shall immediately notify Benefits Administration when the placement order terminates or expires.

b. If a placement order terminates or expires due to the person attaining the legal age of majority, the person may remain an eligible Dependent until age 26 if the Subscriber certifies that the following requirements in (i), (ii) and

(iii) are met:

i. The Subscriber and the person have a relationship as set forth in 26 U.S.C. §152(d)(2), which includes the following relationships:

(1) The person is a descendant of a son/daughter, stepson/stepdaughter of the Subscriber;

(2) The person is a brother/sister, half-brother/half-sister, stepbrother/stepsister, son/daughter-in-law, brother/sister-in-law, or niece/nephew of the Subscriber; or

(3) The person has the same principal place of abode as the Subscriber and is a Member of the Subscriber’s household; and

ii. The Subscriber provides over one-half of the person's financial support for the calendar year in which the Subscriber’s taxable year begins; and

iii. The person is a U.S. citizen, a U.S. national, or a resident of the U.S., Mexico, or Canada; or

c. Additional documents and certifications may be requested to establish that the person is an eligible Dependent.

5. Dependents over the age of 26 years who meet at least one of the criteria in 2 or 3 in this section and who are incapacitated (mentally or physically incapable of earning a living regardless of age, provided the Dependent is incapable of self-sustaining employment). This provision applies only when the incapacity existed before the Dependent’s 26th birthday and the Dependent was enrolled in this vision plan prior to and on their 26th birthday. A request to continue coverage due to incapacity must be provided to Benefits Administration prior to the Dependent’s 26th birthday.

Dependents not eligible for coverage include:

a. Children in the care, custody or guardianship of the Tennessee Department of Children’s Services or equivalent placement agency, who are placed with the Subscriber for temporary or long-term foster care, but not including a person who is placed with the Subscriber for the purpose of adoption;

b. Dependents not listed in the above definitions;

c. Parents of the Employee/Retiree or spouse;

d. Ex-spouse; and

e. Live in companions who are not legally married to the Employee/Retiree.

Employee means a State Employee, Local Education Employee, or Local Government Employee as defined below.

State Employee means:

1. An individual employed by the Employer, who is regularly scheduled to work not less than 30 hours per week;

2. An individual who has received a seasonal appointment and who meets the requirements set forth in TCA 8-27-204(a)(3); or

3. All other individuals required by applicable state or federal law.

Local Education Employee means an Employee of participating agency who is:

1. A teacher as defined in TCA 8-34-101-(49);

2. An interim teacher whose salary is based on the local school system’s schedule;

3. An Employee not defined in 1 or 2 in this section who is regularly scheduled to work at least 30 hours per week in a non-seasonal, non-temporary position;

4. A non-certified Employee who has completed 12 months of employment with a local education agency that participates in the local education insurance plan and works a minimum of 25 hours per week [a resolution passed by the school system’s governing body authorizing the expanded 25-hour rule for the local education agency must be sent to the Policyholder - Benefits Administration before enrollment]; or

5. All other individuals required by applicable state or federal law.

Local Government Employee means an individual who is:

1. Scheduled to work at least 30 hours per week in a non-seasonal, non-temporary position;

2. A Member of the chief legislative body of the county or municipal government (defined as only those elected officials who have the authority to pass local legislation); or

3. A utility district commissioner appointed or elected pursuant to TCA 7-82-307, but only during their term of service.

4. A county official, as defined in TCA 8-34-101(9)(A) and (B), regardless of whether the county participates in the local government plan, pursuant to TCA 8-27-704(a); or

5. All other individuals required by applicable state or federal law.

Employer means the Policyholder and all affiliated employers, including central state government, state higher education, local government agencies and local education agencies that offer this State of Tennessee Group Vision Insurance Program.

Formulary means a list, provided by the Company, of Vision Materials by tier, that are covered under the Policy as shown in the Schedule of Benefits.

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

Low Vision means a severe visual loss that is not correctable with standard lenses and:

1. when the best-corrected acuity is 20/200 or less in the better eye with best conventional spectacle or contact lenses prescription; or

2. when there can be a demonstrated constriction of the peripheral fields in the better eye to 10 degrees or less from the fixation point or the widest diameter subtends an angle less than 20 degrees in the better eye.

Low Vision Aids are classified as follows:

1. Spectacle-mounted magnifiers - A magnifying lens is mounted in spectacles (this type of system is called a microscope) or on a special headband. This allows use of both hands to complete the close-up task, such as reading;

2. Handheld or spectacle-mounted telescopes - These miniature telescopes are useful for seeing longer distances, such as across the room to watch television, and can also be modified for near (reading) tasks;

3. Handheld and stand magnifiers - These magnifiers can serve as supplements to other specialized systems and are convenient for short-term reading of such things as price tags, labels and instrument dials. Both types of magnifiers can be equipped with lights; or

4. Video magnification - Table-top (closed-circuit television) or head-mounted systems enlarge reading material on a video display. Some systems can be used for distance viewing tasks. These are portable systems and can be used with a computer or Computer Display. Image brightness, image size, contrast, foreground/background color and illumination can be customized.

Low Vision Supplemental Examination means diagnostic evaluation beyond the Comprehensive Eye Examination and includes a history of functional difficulties that involves such things as reading, activities in the kitchen, glare problems, mobility, the workplace, television viewing, school requirements, hobbies and interests. Preliminary tests may include assessment of ocular functions such as color vision and contrast sensitivity. Measurements will be taken for visual acuity using special low vision test charts, which include a larger range of letters or numbers to more accurately determine a starting point for assessing the level of impairment. Visual fields may also be evaluated. A specialized Refraction must be performed with each eye thoroughly examined. The Provider may prescribe various treatment options, including Low Vision Aids, as well as assist with identifying other resources for vision and lifestyle rehabilitation.

Medically Necessary Contact Lenses means that adequate functional vision correction cannot be achieved with spectacles but can be achieved with contact lenses. Conditions that qualify for Medically Necessary Contact Lenses are:

1. Anisometropia of 3D in meridian powers;

2. High Ametropia exceeding -12D or +12D in meridian powers;

3. Keratoconus when vision is not correctable to 20/25 in either eye or both eyes using standard spectacle lenses; or

4. vision impairments, other than Keratoconus, when vision can be improved by two lines on the visual acuity chart when compared to best corrected standard spectacle lenses.

Member means an Employee, Retiree, COBRA participant or Dependent who meets the eligibility requirements as shown in this Certificate and whose coverage under the Policy is in force and has not ended.

Out-of-Network Provider means a Provider, located within the PPO Service Area, but is not an In-Network Provider.

Plan Year means the 12-month period beginning January 1 and ending December 31.

Policy means the Vision Insurance Policy issued to the Policyholder.

Policyholder means the State of Tennessee.

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

Preferred Provider Agreement means the agreement between the PPO and a Provider who agrees to become an In-Network Provider. The Preferred Provider Agreement contains the rates and reimbursement methods for services and supplies furnished by an In-Network Provider.

Preferred Provider Organization (“PPO”) means a network of Providers within the PPO Service Area that have signed a Preferred Provider Agreement.

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

Refraction means a test performed by a Provider to determine the glasses or contact lens prescription due to a refractive error (for example, nearsightedness, farsightedness, astigmatism or presbyopia).

Retiree, with eligibility for the State of Tennessee Group Vision Insurance Program, means a State Retiree, Local Education Retiree, or Local Government Retiree as shown below:

State Retiree means an individual who:

1. was hired before July 1, 2015, has left active employment as a State Employee, and is drawing retirement benefits through TCRS based on their own service, or is a participant in a Higher Education Optional Retirement Plan (ORP), as permitted by TCA 8-27-205. Employees whose employment with the State commenced on or after July 1, 2015, are not eligible for coverage as a Retiree unless they were employed by the State or a participating local education agency, as defined in TCA § 8-27-301, before July 1, 2015, and did not accept a lump sum payment from the TCRS before July 1, 2015; or

2. is enrolled in the state’s vision insurance program for active Employees and is a former governor or retired state of Tennessee senator or representative first elected to office prior to July 1, 2015, and meets the requirements set forth in TCA 8-27-208.

Local Education Retiree means:

1. an individual who was hired before July 1, 2015, has left active employment as a Local Education Employee and:

a. if vested in TCRS is drawing retirement benefits through TCRS based on their own service, as permitted by TCA 8-27-305; or

b. if not vested in TCRS is at least age 55 at the time of termination with 10 or more years of service with a participating local education agency or 10 or more years of combined service with a participating local education agency and the State;

2. Employees whose first employment with a participating local education agency commenced on or hired after July 1, 2015, are not eligible for coverage as a retiree unless they were employed by the State or a participating local education agency, as defined in TCA 8-27-301, before July 1, 2015, and did not accept a lump sum payment from the TCRS before July 1, 2015, and meets the requirements set forth in TCA 8-27-305; or

3. Effective January 1, 2026, and thereafter, eligibility to participate in the state retiree vision plan is only open to Retirees of an LEA that is participating in the state vision plan at the time of retirement. If the LEA subsequently terminates participation in the state vision plan, its retirees are no longer eligible to continue retiree vision coverage.

Local Government Retiree means an individual who:

1. Has retired from the participating Employer and:

a. if vested in TCRS, receives a monthly benefit through TCRS based on their own services, as permitted by TCA 8-27-705; or

b. if not vested in TCRS, is at least age 55 at the time of termination with 10 or more years of employment with the participating local government agency from which they retired;

2. Has retired as a utility district commissioner with 20 years of service with the same utility district and is at least age 55 at the time of termination;

3. Has retired as a Member of the chief legislative body of the county or municipal government (defined as only those elected officials who have the authority to pass local legislation) and is at least age 55 at the time of termination with 10 or more years of service with the participating local government agency from which they retired; or

4. Has retired as a county official as defined in 8-34-101(9)(A) and (B) and is at least age 55 at the time of termination with 10 or more years of service with the local government agency from which they retired.

Effective January 1, 2026, and thereafter, eligibility to participate in the state retiree vision plan is only open to Retirees of an LGA that is participating in the state vision plan at the time of retirement. If the LGA subsequently terminates participation in the state vision plan, its retirees are no longer eligible to continue retiree vision coverage. This restriction does not apply to county officials as defined in TCA 8-34-101(9)(A) and (B).

Subscriber means an Employee or Retiree who meets the eligibility requirements as shown in this Certificate, makes the enrollment elections, and whose vision coverage under the Policy is in force and has not ended.

Tennessee Code Annotated (TCA) means the laws passed by the Tennessee General Assembly.

Tennessee Consolidated Retirement System (TCRS) means the defined benefit plan component of the State of Tennessee’s retirement program that provides retirement, survivor and/or disability benefits to eligible Retirees and their eligible Dependents.

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

Vision Materials means those materials provided for visual health and welfare shown in the Schedule of Benefits.

PARTICIPATION REQUIREMENTS

An agency must be participating in the State of Tennessee Sponsored Group Health Program in order to qualify for participation in the State of Tennessee Group Vision Insurance Program. Employees and Dependents of Employees ARE NOT required to participate in a state-sponsored group basic health plan as a condition of participating in the State Group Vision Insurance Program. Retirees and Dependents of Retirees ARE NOT required to participate in a state-sponsored group basic health plan as a condition of participating in the State Group Vision Insurance Program. An Employee or Retiree’s participation in the State Group Vision Insurance Program is required for participation of eligible Dependents, EXCEPT when Dependents are allowed to remain enrolled in the State Group Vision Insurance Program due to the Retiree’s death or applicable COBRA regulations. Participation by those enrolled in the State Group Vision Insurance Program is on a calendar year basis, and enrollment may only be changed or cancelled by the Subscriber during the Annual Enrollment Period for the beginning of the next calendar year or if they experience an event permitting Mid-Year Enrollment or Mid-Year Cancellation of Coverage as provided in this Certificate.

ENROLLMENT DEADLINES AND EFFECTIVE DATES OF COVERAGE

The following Enrollment Deadlines and Effective Dates of Coverage are provided by the State of Tennessee.

Annual Enrollment Elections.

(A) The Vision Plan’s designated annual enrollment period will be announced in an annual enrollment newsletter and will be published on the State’s Partners for Health website. All timely submitted annual enrollment elections and revisions will become effective on January 1 of the upcoming Plan Year and remain in effect through December 31 of the upcoming Plan Year unless a mid- year enrollment change is permitted by this COC.

(B) Employees may make coverage elections during annual enrollment, may choose between any vision option for which the Employee is eligible, and may add or drop eligible Dependents. If no new elections are received by BA during annual enrollment, the coverage in effect immediately prior to annual enrollment is deemed to be elected for the upcoming Plan Year.

(C) When adding new Dependents during annual enrollment, eligibility documentation must be submitted prior to December 1 of the current Plan Year or as otherwise directed by BA. In no event will annual enrollment documentation be accepted after December 31 of the current Plan Year.

(D) During annual enrollment a Retiree may enroll in new coverage, add or drop an eligible Dependent and make changes to existing coverage.

(E) During annual enrollment a surviving Dependent may make changes to existing coverage (switch vision plans) but is not eligible to newly enroll in vision coverage or add new Dependents to existing coverage.

(F) Employees who are eligible for coverage under this Vision Plan and another state-sponsored vision insurance option may switch their coverage (and coverage for their Dependents) to or from the other option during the applicable designated annual enrollment period.

(G) Once the Plan’s designated annual enrollment period has closed, active Employees and eligible Retirees have one opportunity to revise annual enrollment elections provided that requests are submitted to BA no later than 4:30 CT on December 1 of the current Plan Year. Timely submitted revisions will become effective on January 1 of the upcoming Plan Year.

Enrollment Deadlines and Effective Date of Subscriber’s Insurance.

Initial Enrollment and Insurance Elections You must enroll and make insurance elections for yourself and your eligible Dependents by completing electronic enrollment or by signing an approved payroll deduction or enrollment form, as applicable, within thirty (30) calendar days of becoming eligible (hire date for new hires), but no earlier than the date you become eligible to request coverage. The 30 days includes the date you first become eligible.

Participation in this Vision Plan is on a calendar year basis. Changes to coverage or termination of coverage is not available until the Annual Enrollment Period for the beginning of the next calendar year or by experiencing a mid-year enrollment or mid-year termination event as provided in this certificate.

Enrollment Provisions when Employee and Spouse are Both Employed by the Same Employer. A newly hired Employee can enroll an Employee spouse who originally declined coverage as an Employee. An Employee spouse who is added as a Dependent pursuant to this section is not required to meet the provisions of the Mid-Year Enrollment Section. An Employee may not be enrolled as both Subscriber and Dependent within the same group program (state, local education or local government). If both parents of a child qualify as eligible Employees, only one Employee (parent) can enroll Dependent children.

Effective Date of Employee/Retiree Insurance.

State

(1) Newly Hired Employee: Enrollment must be completed and submitted to ABC/BA within 30 calendar days of Employee’s hire date which is their eligibility date. Coverage will begin the first day of the month after the Employee becomes eligible for coverage, the completed enrollment form and documentation is received by ABC/BA, and the Employee has completed one full calendar month of employment with the Employer.

(2) Seasonal Employee Hired Prior to July 1, 2015: Enrollment must be completed and submitted to ABC/BA within 30 calendar days of Employee’s date of becoming eligible for coverage as provided in TCA § 8-27-204(a)(3). Coverage will begin the first day of the month after the Employer certifies that the Employee has met the requirements of TCA 8-27-204(a)(3) and ABC/BA receives a completed enrollment form and documentation.

(3) Existing Employee with at Least One Calendar Month of Employment Followed by gaining eligibility for coverage (including part-time to full-time employment and emergency appointment to permanent appointment): Enrollment must be completed and submitted to ABCBA within 30 calendar days of Employee’s date of becoming eligible for coverage. Coverage will begin the first day of the month after the Employee becomes eligible for coverage and a completed enrollment form and documentation is received by ABC/BA.

Local Education Newly Hired Employee (including Employees moving between LEAs, or coming from LGAs, the State Plans, or Higher Education Institutions): Enrollment must be completed and submitted to ABC/BA within 30 calendar days of Employee’s hire date which is their eligibility date. Coverage will begin the first day of the month after the Employee becomes eligible for coverage, the Employee satisfies any mandatory waiting period, and the ABC/BA timely receives a completed enrollment form and documentation.

Existing Employee gaining eligibility for coverage (including part-time to full-time employment: Enrollment must be completed and submitted to ABC/BA within 30 calendar days of Employee’s date of becoming eligible for coverage. Coverage will begin the first day of the month after gaining eligibility for coverage and ABC/BA’s timely receipt of a completed enrollment form.

Local Government Newly Hired Employee (including Employees moving between LGAs, or coming from LEAs, the State, or Higher Education Institutions): Enrollment must be completed and submitted to ABC/BA within 30 calendar days of Employee’s hire date which is their eligibility date. Coverage will begin the first day of the month after the Employee is eligible for coverage, the Employee satisfies any mandatory waiting period, and the ABC/BA receives a timely completed enrollment form and documentation.

Existing Employee gaining eligibility for coverage (including part-time to full-time employment); Enrollment must be completed and submitted to ABC/BA within 30 calendar days of Employee’s date of becoming eligible for coverage. Coverage will begin the first day of the month after the Employee becomes eligible for coverage and the ABC/BA receives a timely completed enrollment form.

Effective Date of Dependents’ Insurance. The effective date of coverage for any eligible Dependent shall be the later of the effective of your coverage as a Subscriber or the first day of the month after the Dependent becomes an eligible Dependent and ABC/BA is in receipt of a timely completed enrollment election form and documentation as otherwise stated in this certificate.

Transfer from Prior Contract means that individuals enrolled under the prior vision insurance contract with the State immediately prior to the effective date of this vision plan will be automatically enrolled under the new vision insurance contract for this Plan with the State with no break in coverage if premium payments were current and the Subscriber did not make a change during the State’s Annual Enrollment. Benefit frequencies and other limitations under this vision insurance contract will not incorporate Subscriber’s experience under the prior vision insurance contract.

Events Permitting Mid-Year Enrollment. Without regard to the dates or circumstances on which an individual would otherwise be able to enroll in this vision plan current Employees/Retirees and Dependents as defined in this certificate are permitted to enroll in coverage under this vision plan if the Employee/Retiree or Dependent meets the following conditions, as stated in “Loss of Eligibility for Other Coverage” or “Acquisition of New Dependents” below.

· Loss of Eligibility for Other Coverage.

An Employee/Retiree or Dependent, otherwise eligible to enroll in a vision benefit plan, may be enrolled through this Mid-Year Enrollment provision, provided that they:

1. Declined coverage in a state-sponsored vision insurance plan when it was previously offered during their initial eligibility period or during a subsequent Annual Enrollment Period;

2. Had coverage under any group vision insurance plan at the time this coverage was previously offered; and

3. Experience a loss of eligibility for other vision insurance coverage for reasons including the following (but not for a failure to pay premiums or termination for cause):

a. Death;

b. Divorce;

c. Legal separation;

d. Cessation of Dependent status;

e. Termination of employment (voluntary and non-voluntary);

f. Employer’s discontinuation of contribution to insurance coverage (total contribution, not partial);

g. Reduction in number of work hours of employment;

h. Spouse maintaining coverage that has reached their lifetime maximum (if legally permitted);

i. The loss of eligibility due to an HMOs failure to provide benefits in the area where the individual lives, works, or resides; or

j. Loss of vision benefits through TennCare or Children’s Health Insurance Program (CHIP) coverage other than non-payment of premium, or expiration of COBRA coverage.

If an Employee/Retiree satisfies all three requirements above, the Employee/Retiree and all Dependents of the Employee/Retiree are eligible for Mid-Year Enrollment to this vision plan.

If a Dependent satisfies all three requirements above, only that Dependent, the Employee/Retiree, and other Dependents satisfying the requirements above are eligible for Mid-Year Enrollment to this vision plan.

All Mid-Year Enrollment requests due to Loss of Eligibility for Other Coverage and required documentation must be submitted to and received by the ABC/BA within 60 calendar days of the loss of eligibility for other coverage.

The effective date of coverage due to Loss of Eligibility for Other Coverage shall be the first day of the first calendar month after both the loss of eligibility and the date the ABC/BA receives the request for Mid-Year Enrollment.

Substantiation of Loss of Coverage. If requesting Mid-Year Enrollment based on loss of eligibility for other coverage, the Employee/Retiree must submit appropriate documentation to substantiate all of the following:

1. That the Employee/Retiree or Dependent was covered by another group vision insurance plan at the time they declined the offer of this coverage; and

2. That the Employee/Retiree experienced an event resulting in the Employee/Retiree or Dependent’s loss of eligibility for coverage under the other group vision insurance plan, and the date of the Employee/Retiree or Dependent’s loss of eligibility.

· Acquisition of New Dependents When an Employee/Retiree acquires a new Dependent by marriage, birth, adoption, or placement for adoption, the Employee/Retiree, Spouse, and any Dependent may be enrolled by Mid-Year Enrollment. When an Employee/Retiree acquires a new Dependent by a legal guardianship order placing child in the custody of the Employee/Retiree and requiring Employee/Retiree to provide insurance coverage for the new Dependent, only the Employee/Retiree and new Dependent may be enrolled by Mid-Year Enrollment.

Any coverage changes made as a result of a Mid-Year Enrollment shall be on account of and correspond with the change in status that affected eligibility for coverage under this vision plan.

All enrollment applications based upon the acquisition of a new Dependent and required supporting documentation must be submitted to and received by the ABC/BA within sixty (60) calendar days of the acquisition date.

The effective date of coverage for a Mid-Year Enrollment for acquiring a new Dependent shall be prospective only from the first day of the first calendar month after both the acquisition of the new Dependent and the date the ABC/BA receives the request for Mid-Year Enrollment.

Substantiation of Acquiring a New Dependent. If requesting enrollment based on acquiring a new Dependent, the Employee/Retiree must submit appropriate documentation as listed on the enrollment application to substantiate the following:

1. The date of birth of a child;

2. The date of the order of adoption or of the order placing the child in custody for adoption;

3. The date of guardianship specified by the order granting guardianship of the person and requiring financial support and insurance coverage; or

4. The date of marriage.

Plan Cancellation and Termination Provisions Cancellation Provisions. Subscribers may not terminate vision coverage outside of the Annual Enrollment Period unless they experience one of the reasons listed in “Voluntary Termination of Coverage” or “Involuntary Termination of Coverage” below.

Voluntary Termination of Coverage. Voluntary termination of Subscriber or Dependent coverage outside of the Annual Enrollment Period is prohibited unless the Subscriber or Dependent experiences one of the events listed below. For all events the Section 125 consistency rule must be met. For Active Subscribers, the Cancel Request Application Form and required documentation must be received by the ABC/BA within 60 days from the date of the event. For Active Subscribers, if the status change event is new entitlement to Medicare or Medicaid, the Insurance Cancel Request Application Form must be received by BA within 60 days from the date of the Subscriber/Dependent’s receipt of notice of the new entitlement Retiree Subscribers do not have a deadline for submission of the Cancel Request Application form. The effective date of voluntary coverage termination is the first day of the calendar month following ABC/BA’s receipt of the Insurance Cancel Request Application Form and required documentation. Permissible voluntary coverage termination events are as follows:

1. New eligibility for group vision insurance/benefits through spouse or Dependent’s employer;

2. Annual enrollment into a spouse, former spouse, or Dependent’s employer’s group vision insurance plan;

3. New entitlement to Medicare or Medicaid;

4. Termination of child support order of Dependent child provided by National Medical Support Notice; or

5. Change of residence out of the national service area.

Involuntary Termination of Coverage. Coverage terminates involuntarily when a Member ceases to satisfy coverage eligibility requirements of this vision plan or fails to make premium payments in the manner required by BA. Unless otherwise expressly provided in this vision plan, involuntary termination is effective as follows:

1. Coverage of the Subscriber shall terminate upon the earliest to occur of the following:

a. The last day of the month in which the Employee separates employment with the Employer and does not enroll in the vision insurance program as a Retiree or otherwise loses eligibility for coverage (this only applies to central state government Employees);

b. The last day of the month following the month in which the Employee separates employment with the Employer and does not enroll in the vision insurance program as a Retiree or otherwise loses eligibility for coverage (state higher education, local education and local government);

c. The last day of the month in which the agency participates in this Vision Plan (local education and local government agencies only):

d. The last day of the month for which the Employee’s last contribution was applied;

e. The date of the Subscriber’s enrollment in the State of Tennessee’s Sponsored Group Basic Health Insurance Program for Retirees terminates;

f. The date this vision plan is amended to terminate the coverage of a class of Employees of which the Subscriber is a member;

g. the date the Subscriber is no longer eligible for insurance; or

h. The date this vision plan is terminated.

2. An enrolled Dependent’s insurance will cease on the earlier of:

a. the date the Subscriber’s coverage ends unless the Dependent is eligible for continued coverage as a Dependent of a Retiree and is enrolled in one of the state sponsored group basic health insurance plans;

b. the end of the month in which the enrolled Dependent ceases to be an eligible Dependent as defined in this Certificate;

c. the date the enrolled Dependent’s enrollment in the State of Tennessee’s Sponsored Group Basic Health Insurance Plan for Retirees and Dependents terminates; or

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

It is the responsibility of the Subscriber to immediately notify the Employer (if the Subscriber is an Employee) or BA (if the Subscriber is a Retiree) of a status change event causing a Dependent to become ineligible for coverage. When failure to notify the Employer or BA results in claims paid for ineligible Dependents, all claim amounts will be recovered from the Subscriber.

Pending Divorce Actions. If a Subscriber submits a timely request to terminate coverage of a Dependent for any of the above listed Mid-Year change events or drops coverage of a Dependent during annual enrollment while a divorce case is pending, the termination will be processed and final. Court orders in matters to which the State is not a party have no application to the vision plan offered by the State and do not entitle the Subscriber to rescind a termination request or to permit re-enrollment of a Dependent.

It is the responsibility of the Subscriber to comply with all applicable law regarding termination of vision insurance while a divorce action is pending. Neither the State, BA, nor the vision plan is responsible for said compliance or the Subscriber’s failure to comply.

BA may rely upon the direction, information, or election of a Subscriber to remove a Dependent while a divorce action is pending as being proper and in compliance with all legal requirements and the State shall not be responsible for removal of a Dependent if it is determined that the Subscriber’s request was in violation of court orders or applicable law, or if proper notice was not provided by the Subscriber to the Dependent.

A former or ex-spouse is not eligible for coverage on the vision plan even if a court order requires the Subscriber to provide vision insurance coverage to a former/ex-spouse. If a spouse ceases to be eligible due to divorce from a Subscriber, that spouse shall be eligible to continue Coverage through COBRA.

BENEFITS

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

In-Network Provider Benefits. The Insured Person must pay any Copayment 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 on behalf of the Member.

Out-of-Network Provider Benefits. The Member 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, unless the Out-of-Network Provider allows assignment of benefits. The Company will pay the Out-of-Network benefits up to the maximum dollar amount shown in the Schedule of Benefits.

LIMITATIONS

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 Member 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.

EXCLUSIONS

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

1. medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures;

2. Refraction, when not provided as part of a Comprehensive Eye Examination;

3. 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;

4. orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses;

5. any Vision Examination or any corrective Vision Materials required by the Employer as a condition of employment;

6. safety eyewear;

7. solutions, cleaning products or frame cases;

8. non-prescription sunglasses;

9. plano (non-prescription) lenses;

10. plano (non-prescription) contact lenses;

11. two pair of glasses in lieu of bifocals;

12. electronic vision devices, except as provided in the Low Vision Aids benefit;

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

14. lost or broken lenses, frames, glasses, or contact lenses that are replaced before 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 pursuant to the terms of the contract between the State of Tennessee and the Company (contract no. 73804).

For All Subscribers. The Subscribers’ insurance will cease on the earlier of:

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 last day of the month in which the Subscriber separates from active employment with the Policyholder for central state government Employees;

4. the last day of the month following the month of the Subscriber’s separation from active employment with the Policyholder for non-central state government Employees (state higher education, local education, and local government Employees);

5. the date of the Subscriber’s enrollment in the State of Tennessee’s Sponsored Group Health Insurance Plan for Retirees terminates; or

6. the date the Subscriber is no longer eligible for insurance.

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

1. the date the Subscriber’s coverage ends;

2. the end of the month in which the enrolled Dependent ceases to be an eligible Dependent as defined in the Policyholder’s application;

3. the date the enrolled Dependent’s enrollment in the State of Tennessee’s Sponsored Group Basic Health Insurance Plan for Retirees and Dependents terminates; or

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

For an incapacitated Dependent child, the Company may ask for proof of the eligible Dependent child’s incapacity and dependency within 31 days of the date the Dependent child would otherwise cease to be covered.

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

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.

Survivor means that for a:

1. Survivor in Current Plan – Upon the Subscriber’s death, surviving Dependents covered under this vision plan on the date of a Subscriber’s death may continue their enrollment in this vision plan with one of the two options listed below.

a. Deceased Subscriber was eligible for continuation of coverage as a Retiree at time of death - Dependents may elect COBRA or Retiree continuation of vision elections in effect for them on the date of Subscriber’s death; or

b. Deceased Subscriber was not eligible for continuation of coverage as a Retiree at time of death – Dependents may elect COBRA continuation for vision elections in effect for them on the date of Subscriber’s death.

2. Survivor with New Local Government or Local Education Agency Joining Plan – Upon a new agency joining the State Group Insurance Program (SGIP), surviving Dependents of deceased Employees or Retirees may enroll in this vision plan if the following criteria is satisfied.

a. The new agency opts to offer the SGIP vision insurance plan to its Employees;

b. Surviving Dependents were enrolled in COBRA or the new agency’s regular vision insurance plan and the agency’s medical plan in the month prior to the new agency joining the SGIP; and

c. Surviving Dependents choose to enroll in the SGIP medical and vision insurance programs.

For a new local education Agency, Retiree coverage shall not be available to Survivors of a deceased Retiree whose employment with a participating agency commenced on or after July 1, 2015.

PREMIUMS

The Company provides insurance coverage in return for premium payment. Premiums are payable to the Company by the Policyholder on behalf of the Members. The Member’s first premium is due on the Member’s Effective Date. Premiums must be paid to the Company on or before the due date. The initial premium rates are shown in the Policyholder’s application.

Premium Changes. The Company has the right to change the premium rates according to the terms of the Company’s contract with the State of Tennessee (contract no. 73804).

Grace Period. The Policy has a 31-day grace period for the payment of each premium due after the first premium. Coverage will continue in force during the grace period. Coverage will terminate at the end of the grace period if all premiums due are not paid. The Company will require payment of all premiums for the period this coverage continues in force, including the premiums for the grace period. The grace period will not apply if the Company receives written notice of the Policyholder’s or the Subscriber’s intent to terminate coverage.

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 Member 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 Member will be deemed as notice to the Company.

Claim Forms. The Company will furnish claim forms to the Member within 15 days after notice of claim is received. If the Company does not provide the forms within that time, the Member 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 within 30 days, upon receipt of due written proof of loss.

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

Assignment. Benefits under the Policy may be assigned.

Right of Recovery. If payment for claims exceeds the amount for which the Member 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 Subscriber, within 18 months from the date the claim is paid.

Legal Actions. No Member can bring an action at law or in equity against the Company 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 Member resides, the limit is extended to meet the minimum time allowed by such law. Nothing in this document shall be construed to be a waiver of sovereign immunity by the State of Tennessee.

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 Insurance Obligation. The Policy, including any endorsements and riders, this Certificate, the Policyholder’s application, which is attached to the Policy when issued, constitutes the entire agreement between the Company and the Members. A copy of the Policy may be examined at the office of the Policyholder during normal business hours.

Amendments and Changes. No Member is authorized to alter or amend the Policy, or to waive any conditions or restrictions herein, or to extend…