Group Vision Care Plan

	Vision Care for Life

EVIDENCE OF COVERAGE
&
DISCLOSURE FORM

Provided by:
VISION SERVICE PLAN

3333 Quality Drive, Rancho Cordova, CA  95670
(916) 851-5000 (800) 877-7195

THIS EVIDENCE OF COVERAGE AND DISCLOSURE FORM DISCLOSES THE TERMS AND CONDITIONS OF COVERAGE.  PLEASE READ THE FORM COMPLETELY AND CAREFULLY.  INDIVIDUALS WITH SPECIAL HEALTHCARE NEEDS SHOULD CAREFULLY READ THOSE SECTIONS THAT APPLY TO THEM.  ALL APPLICANTS HAVE A RIGHT TO REVIEW THE EVIDENCE OF COVERAGE AND DISCLOSURE FORM PRIOR TO ENROLLMENT.

CAASP-00890 		

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

NAME OF EMPLOYER: The County of San Diego
NAME OF PLAN: Signature Plan
PRINCIPAL ADDRESS:5530 Overland Ave. Ste. 210, San Diego, CA 92123-1261

EMPLOYER I.D.#: 

PLAN #:00107506

PLAN ADMINISTRATOR: The County of San Diego
ADDRESS: 5530 Overland Ave. Ste. 210, San Diego, CA 92123-1261

PHONE NUMBER: (619) 531-6057

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

ADDRESS:

THIS EVIDENCE OF COVERAGE AND DISCLOSURE FORM CONSTITUTES ONLY A SUMMARY OF THE TERMS AND CONDITIONS OF COVERAGE.  THE PLAN CONTRACT ITSELF SHOULD BE CONSULTED TO DETERMINE GOVERNING TERMS AND CONDITIONS OF COVERAGE.

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 Plan.	
		
ANISOMETROPIA	A condition of unequal refractive state for the two eyes, one eye requiring a different lens correction than the other.	
		
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 this plan.	
		
ELIGIBLE DEPENDENT	Any legal dependent of an Enrollee of Group who meets the criteria for eligibility established by Group and approved by VSP under section VI. ELIGIBILITY FOR COVERAGE of the Group Plan document maintained by your Group Administrator 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 Group Plan document maintained by your Group Administrator.	
		
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 plan in order to provide vision care coverage to its Enrollees and their Eligible Dependents.	

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KERATOCONUS	A development or dystrophic deformity of the cornea in which it becomes cone shaped due to a thinning and stretching of the tissue in its central area.	

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 this plan, as defined on the enclosed insert or in the Schedule of Benefits attached as Exhibit A to the Group Plan document 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 Plan document maintained by your Group Administrator.	
		
RENEWAL DATE	The date on which this plan shall renew or terminate if proper notice is given.	
		
SCHEDULE OF BENEFITS	The document, attached as Exhibit A to the Group Plan 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 this plan.	
		
SCHEDULE OF PREMIUMS	The document, attached as Exhibit B to the Group Plan 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 eligible for coverage, a person must currently be an employee or member of the Group, and meet the criteria established in the coverage criteria mutually agreed upon by Group and VSP.

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

A dependent, unmarried child over the limiting age as shown on the enclosed insert 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.

ANNUAL ENROLLMENT/DISENROLLMENT
Except for new Enrollees joining this plan, Enrollees and Eligible Dependents shall have the right to become covered or cancel coverage once each year during open enrollment and the effective date will be January 1st of the subsequent year.  Any such coverage or cancellation of coverage may be accomplished only by Group giving VSP written notice thereof on behalf of the Enrollee or Eligible Dependent before the end of the prescribed thirty (30) day period and will take effect on the anniversary date following receipt of such notice.

PREMIUMS
Your Group is responsible for payments to VSP of the periodic charges for your coverage.  You will be notified of your share of the charges, if any, by your Group.  The entire cost of the program is paid to VSP by your Group.

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PROCEDURES FOR USING THIS PLAN

PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.

1.	When you desire to obtain Plan Benefits from a Member Doctor, you should contact a Member Doctor or VSP.  A list of names, addresses, and phone numbers of Member Doctors in your geographic location can be obtained from your Group, Plan Administrator, or VSP.  If this list does not cover the geographic area in which you desire to seek services, you may call or write the VSP office nearest you to obtain one which 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 knows to 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 this plan in spite of your termination of coverage or the termination of this plan. Should you receive services from a Member Doctor without such Benefit Authorization or obtain services from a provider who is not a Member Doctor, you are responsible for payment in full to the provider.

4.	You pay only the Copayment (if any) to the Member Doctor for the services covered by this plan.  VSP will pay the Member Doctor directly according to their agreement with the doctor.  VSP reimburses its Member Doctors on a fee-for-service basis.  There are no incentives or financial bonuses paid to Member Doctors for services covered under this plan.

Note:  If you are eligible for and obtain Plan Benefits from a Non-Member Provider, you should pay the provide their 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 remain 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 authorized 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 Plan. When Covered Person requests services under this Plan, 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 Plan’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.

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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.

IMPORTANT:  The benefits described below are typical services and materials available under most VSP plans. However, the actual Plan Benefits provided to you by your Group may be different. Refer to the attached Schedule of Benefits and/or Disclosure to determine your specific Plan Benefits.

1.	Eye Examination:  A complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of corrective eyewear where indicated.  Each Covered Person is entitled to a Eye Examination as indicated on the enclosed insert.

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.  Each Covered Person is entitled to new lenses as indicated on the enclosed insert.

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.  Each Covered Person is entitled to new frames as indicated on the enclosed insert.

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. 

When you obtain Necessary contact lenses from a Member Doctor, professional fees and materials will be covered 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.  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 one of the Member Doctors, 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 their 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.

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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 Plan is designed to cover visual needs rather than cosmetic materials. If you select any of the following extras, this Plan  will pay the basic cost of the allowed lenses or frames, and you will be responsible for the additional costs for the options, unless the extra is defined as a Plan Benefit in the enclosed Schedule of Benefits insert.

•	Optional cosmetic processes.
•	Anti-reflective coating.
•	Color coating.
•	Mirror coating.
•	Blended lenses.
•	Cosmetic lenses.
•	Laminated lenses.
•	Oversize lenses.
•	Photochromic lenses, tinted lenses except Pink #1 and Pink #2.
•	Progressive multifocal lenses.
•	UV (ultraviolet) protected lenses.
•	Certain limitations on low vision care.

NOT COVERED
There is no benefit under this plan for professional services or materials connected with:

•	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.

•	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.

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

•	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.

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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.

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.  

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 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.

C.	Review by the Department of Managed Health Care: The California Department of Managed Health Care is responsible for regulating health care service plans.  If you have a grievance against your health plan, you should first telephone your health plan at (800) 877-7195 and use your health plan's grievance process before contacting the Department.  Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.  If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance.

The Department also has a toll-free telephone number (1-888-HMO-2219), a TDD line (1-877-688-9891) for the hearing impaired and its Internet Web site (http://www.hmohelp.ca.gov) has complaint forms online. The plan’s grievance process and the Department's complaint review process are in addition to any other dispute resolution procedures that may be available to Covered Persons, and the failure to use these procedures does not preclude Covered Person's use of any other remedy provided by law.

ARBITRATION
Any dispute or question arising between VSP and Group or any Covered Person involving the application, interpretation, or performance under this plan shall be settled, if possible, by amicable and informal negotiations. This will allow such opportunity as may be appropriate under the circumstances for fact-finding and mediation. If any issue cannot be resolved in this fashion, it shall be submitted to arbitration. The procedure for arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration Association.

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TERMINATION OF BENEFITS

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

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 of the Group who may desire to retain their coverage.

THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985 (COBRA)
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under certain circumstances, health plan benefits available to an eligible Enrollee and their or her Eligible Dependents be made available for purchase by said persons upon the occurrence of a COBRA-qualifying event.  If, and only to the extent COBRA applies, VSP shall make the statutorily-required continuation coverage available for purchase in accordance with COBRA.

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VISION SERVICE PLAN
3333 Quality Drive
Rancho Cordova, CA  95670
Group Name:	COUNTY OF SAN DIEGO	
			
Plan Number:	00107506	
			
Effective Date:	JANUARY 1, 2022	
			
Plan Term:	TWELVE (12) MONTHS	

VISION CARE PLAN
DISCLOSURE FORM AND EVIDENCE OF COVERAGE
PLAN ADMINISTRATOR:	Jan Mazone	
	(Name)	
	5530 Overland Ave Ste 210 Mail Stop O-7	
	(Address)	
	San Diego,  CA 92123-1261	
	(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:  DEPENDENT CHILDREN ARE COVERED TO THE END OF THE MONTH IN WHICH THEY TURN AGE 26. THE WAITING PERIOD IS THE SAME AS YOUR OTHER HEALTH BENEFITS.	
PLAN AND SCHEDULE:	SIGNATURE PLAN                        	
	EXAMINATION:	ONCE EVERY PLAN YEAR*	
	LENSES:	ONCE EVERY PLAN YEAR*	
	FRAMES:	ONCE EVERY TWO PLAN YEARS*	
	*PLAN YEAR BEGINS   JANUARY 1ST.
TERM, TERMINATION AND RENEWAL:	AFTER THE PLAN TERM, THIS PLAN 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:	VSP WILL PROVIDE ADMINISTRATIVE SERVICES OF THE FOLLOWING NATURE:  CLAIM AND BILLING ADMINISTRATION.  BENEFITS PROVIDED UNDER THIS PLAN ARE SELF-INSURED BY THE EMPLOYER.	
VSP'S ADDRESS IS:	VISION SERVICE PLAN
3333 QUALITY DRIVE
RANCHO CORDOVA, CA  95670	

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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.

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 $	      40.00*	

VISION CARE MATERIALS				
				
Lenses				
	Single Vision	Covered in Full*	Up to $	      40.00*	
	Bifocal	Covered in Full*	Up to $	      60.00*	
	Trifocal	Covered in Full*	Up to $	      80.00*	
	Lenticular	Covered in Full*	Up to $	    125.00*	
				
Frames	Covered up to $150 
Retail Allowance*	Up to $	     45.00*	

CONTACT LENSES			
				
Necessary				
  Professional Fees and Materials	Covered in Full*	Up to $	   210.00*   	
				
Elective				
  Professional Fees** and Materials	Up to $ 150.00	Up to $	   105.00	

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.

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LENS OPTIONS

Scratch coating	Covered in full	Not Covered
Polycarbonate Lenses	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.

COPAYMENT
A Copayment amount of $15.00 shall be payable by the Covered Person to the Member Doctor or Non-Member Doctor at the time services are rendered.

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 24 months.

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.

ADDENDUM

LASER VISIONCARESM  PREFERRED PROGRAM
SCHEDULE OF BENEFITS

VISION SERVICE PLAN

Covered Persons who meet the eligibility requirements outlined under Eligibility herein are entitled to the following laser vision correction benefits, subject to the conditions, limitations and exclusions as stated herein.

DEFINITIONS

Primary Eye Care Doctor:  A VSP participating doctor who performs consultation, preoperative examinations and postoperative examinations. Laser Vision Correction Primary Eye Care Doctors are doctors with special training in the co-management of laser vision correction patients.

Laser In Situ Keratomileusis (LASIK):  A procedure performed with a laser light beam during which a small, thin flap is made on the cornea allowing the laser to reshape the exposed corneal tissue.  

Participating Laser Vision Correction (LVC) Facilities:  Facilities that have contracted with VSP to provide Laser Vision Correction services to Covered Persons in coordination with Participating Surgeons. 

Participating Surgeon: A VSP participating provider who is licensed as a doctor of Ophthalmology in the State in which he/she practices and who is contracted with VSP to perform surgical and advanced eye care, including Laser Vision Correction services.

Photorefractive Keratectomy (PRK) Laser Refractive Surgery:  A procedure to correct nearsightedness which is performed with an excimer laser using a laser light beam to reshape the surface of the cornea.

Laser Vision Correction Surgery: The surgical procedures used to correct vision problems (such as nearsightedness, farsightedness, and astigmatism) covered under this Plan and provided by a coordinated network of Primary Eye Care Doctors, Participating Surgeons and Participating LVC Facilities.

Custom LASIK: A type of technology used in LASIK surgery, also called wavefront-guided LASIK. This wavefront technology measures the eye from front to back to create a three-dimensional corneal map. This measurement then guides the laser to reshape the cornea.

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ELIGIBILITY

The following are Covered Persons under this Plan:

•	Enrollee
•	The legal spouse of Enrollee
•	Any child of Enrollee, 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.
•	The domestic partner of the same or opposite in gender as Enrollee, pursuant to the Group's eligibility rules which are applicable to the Group's general medical benefits.

Dependent children and students are covered until the end of the month in which they reach age 26.

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 Enrollee for support and maintenance.

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

COVERED SERVICES 

Laser Vision Correction Surgery is used to correct vision problems such as nearsightedness, farsightedness, and astigmatism.  Covered Persons are entitled to the following Laser Vision Correction benefits when obtained from VSP Primary Eye Care Doctors, Participating Surgeons and Participating LVC Facilities, subject to the payment responsibility of Covered Persons as noted in the second column:

Covered Service						Covered Person Benefit

Initial consultation 							No cost
		
Preoperative Exams						No cost* 

PRK, LASIK, or Custom LASIK Surgery	$500.00 per-eye allowance**

Postoperative examinations						No cost (included in surgery fee)

Enhancement surgery						No cost
(Only covered if needed and if performed within the time period specified by the Participating Laser Vision Correction Facility)
	
*If a Covered Person obtains initial consultation services and/or preoperative exams, but surgery is not indicated or performed, this Plan will cover the costs of one such round of preoperative services.  Such costs will not count towards a Covered Person’s benefit allowance for laser vision correction surgery, which may be obtained at a later date.

**This plan provides an allowance of $500.00 per eye to be paid towards the above Laser Vision Correction Surgery services. VSP has contracted with the Participating Laser Vision Correction Facilities to provide discounts to VSP members. The discounted price will not exceed $1800 per eye for LASIK, $1500 per eye for PRK, and $2300 per eye for Custom LASIK.  In the event that a Covered Person receives Laser Vision Correction services on one eye only, any remaining balance may not be applied towards the cost of surgery in the second eye.
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HOW DOES THE PLAN WORK?

STEP ONE:  	Call VSP’s Customer Service Department at (800) 877-7195 to locate a Primary Eye Care Doctor and identify yourself as a Covered Person.  Your VSP participating doctor may be a Laser Vision Correction Primary Eye Care Doctor.  When you call Customer Service, you may verify your doctor’s participation.

STEP TWO:	Call a Laser Vision Correction Primary Eye Care Doctor and identify yourself as a Covered Person.  Tell the doctor that you are using the Laser VisionCare benefit.   The doctor will need your identification number (usually Social Security Number) and your group name.

STEP THREE:	The doctor will perform an examination to determine if you are a candidate for Laser Vision Correction Surgery and discuss the benefits, risks and alternatives to surgery.  If you wear contact lenses, you may need to see the Co-Manager several times before you are ready for surgery, to ensure your vision is stable.  If you are a candidate for Laser Vision Correction Surgery, the Co-Manager will refer you to a Participating LVC Surgeon/Facility.

STEP FOUR:	Make an appointment with the VSP Participating LVC Surgeon/Facility.  Your doctor may schedule this appointment for you.  This appointment is usually at a Participating LVC Facility.  The Participating Surgeon will:

•	Discuss the procedure and answer any questions
•	Have you review and sign the informed consent documentation
•	Perform the surgery  

Prior to the surgery, the Participating LVC Facility will collect your share of the surgery fee.

STEP FIVE:	Post-surgical care will be coordinated by your Primary Eye Care Doctor and Participating Surgeon. You will likely visit the doctor several times after the surgery to ensure your eyes heal properly.

13	

WHAT IF I USE A NON-PARTICIPATING DOCTOR?

VSP’s Participating Primary Eye Care Doctors, Surgeons and LVC Facilities provide Covered Persons with quality laser vision correction services at competitive fees.  By using participating doctors, you can be assured you are receiving the highest quality care.

You may obtain Laser Vision Correction Surgery services from Non-Member Providers and will receive an allowance of $500.00 per eye towards the surgery and any associated pre and post operative services.

THERE IS NO ASSURANCE THAT THE NON-MEMBER PROVIDER ALLOWANCE WILL BE SUFFICIENT TO PAY FOR THE ENTIRE COST OF SERVICES. FEES FOR LASER VISION CORRECTION SERVICES RECEIVED FROM NON-MEMBER PROVIDERS ARE NOT SUBJECT TO A NEGOTIATED DISCOUNT.  ANY COSTS ABOVE THE NON-MEMBER PROVIDER ALLOWANCE ARE NOT NEGOTIATED BY VSP AND ARE THE RESPONSIBILITY OF THE MEMBER.  

The Covered Person should pay the Non-Member Provider’s full fee and request a copy of the bill and surgery report.  Send a copy of the itemized bill(s) to VSP.  Include the following information:

•	Name and mailing address
•	Identification number (typically Social Security number)
•	Your Employer 
•	Please write “PRK”, “LASIK”, or “Custom LASIK” on all receipts.

The above information should be submitted to VSP along with a CMS-1500 form or any generic insurance claim form that may be available from the Non-Member Provider.  Mail the information to:

VSP
PO Box 385018
Birmingham, AL 35238-5018

VSP will reimburse the Covered Person up to the Non-Member Provider Allowance amount for services received.   Laser Vision Correction Surgery benefits obtained from a Non-Member Provider are subject to the same limitations as described below. 
14	

EXCLUSIONS AND LIMITATIONS

Limitations:

Covered Laser Vision Correction Surgery benefits are available to Covered Persons, once per eye per lifetime. Covered Persons are financially responsible for the costs of any additional professional and/or facility services received.

Exclusions:  

The following services and/or supplies are not covered under your Laser Vision Correction benefits:

1.	Forms of laser vision correction surgery other than PRK, LASIK, and Custom LASIK, including but not limited to Radial Keratotomy.
2.	Prescription drugs.
3.	Orthoptics or vision training and any associated supplemental testing.
4.	Prescription glasses or contact lenses are not covered under this plan.  Covered Persons may be eligible for routine vision materials under another VSP vision plan.
5.	Pathological treatment.
6.	Inpatient hospital and anesthesia costs for covered services not able to be provided on an outpatient basis.
7.	Services provided by providers who are not contracted Primary Eye Care Doctors, Participating Surgeons or Participating LVC Facilities, except as provided above.
8.	Services not indicated as covered Plan Benefits on this Summary of Benefits.

15	

Summary of Benefits and Coverage
SIGNATURE PLAN

Prepared for:  		COUNTY OF SAN DIEGO
Group ID:  		00107506  
Effective Date:		JANUARY 1, 2022
The Affordable Care Act requires that health insurance companies and group health plans provide consumers with a simple and consistent benefit and coverage information document, beginning September 23, 2012. This document is a Summary of Benefits and Coverage (SBC).
The grid below is being provided for your convenience and mirrors the sample SBC that the U.S. Department of Labor has published.  All the information provided is relative to your plan and described in detail in the preceding Evidence of Coverage.

Common	Services You	Your cost if you use an	Limitations and	
Medical	May Need	In-Network	Out-of-Network	Exceptions	
Event		Provider	Provider		
If you or your dependents (if applicable) need eyecare	Eye Exam	*Covered in Full
	Reimbursed up to 
$40.00	Exam covered in full every 12 months**	
	Frames, Lenses or 
Contacts	*$150 Allowance or $150 For Contacts
	Frames reimbursed up to $ 45.00 
SV Lenses reimbursed up to $ 40.00
Bi-Focal Lenses reimbursed up to 
$ 60.00
Tri-Focal Lenses reimbursed up to
$ 80.00
Lenticular Lenses reimbursed up to
$125.00
ECL reimbursed up to $105.00	Frames covered every 24 months**
Lenses covered every 12 months** 	
	Fees	$15.00 Copay			
* Fees copay applies to first service used.
** Beginning with the first day of the Benefit Period.	
Your Grievance and Appeals Rights: 
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: 800-877-7195.