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HomeMy WebLinkAbout1989-073 5 6 7 8 9 10 11 12 13 14 15 16 17 18 . . 1 RESOLUTION NO. 89-73 2 3 4 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE EXECUTION OF AN AMENDMENT TO AGREEMENT WITH PRIVATE MEDICAL CARE, INC., EXTENDING THE TERM FOR AN ADDITIONAL YEAR EFFECT- IVE JANUARY 1, 1989. BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN BERNARDINO AS FOLLOWS: SECTION 1. The Mayor of the City of San Bernardino is hereby authorized and directed to execute on behalf of said City an amendment to agreement with Private Medical Care, Inc., extending the term for an additional year, effective January 1, 1989, relating to an Optical Plan for employees and dependents, a copy of which is attached hereto, marked Exhibit "A" and incorporated herein by reference as fully as though set forth at length. I HEREBY CERTIFY that the foregoing Resolution was duly adopted by the Mayor and Common Council for the City of San regular Bernardino at an adjourned/ meeting thereof, held on the 13th day of March , 1989, by the following vote, to 19 wit: 20 21 22 23 24 25 26 27 28 AYES: Council Members Reilly, Flores, Maudsley, Minor, Pope-Ludlam, Miller NAYS: None ABSENT: Council Member Estrada lti!~~{/ -~~9 II RESOLUTION TO AMEND AGREEMENT WITH PRIVATE MEDICA~-CARE; INC., TO EXTEND TERM OF AGREEMENT AN ADDITIONAL YEAR EFFECTIVE JANUARY 1, i 989 ' The foregoing resolution is hereby approved this I~~~ , 1989. MaY~~ ?&~no 1 2 3 4 5 day of March 6 Approved as to form and legal content: 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 ;/~ 23 '[I) . . .. DENTAL HEALTH PLAN II AffiHa~d with Ddta D'nta\ P\,n OPTOMETRIC HEALTH CARE AGREEMENT -Prepaid- THIS AGREEMENT is made and entered into this /~~day of J11~J~ , 198Q, by and between PRIVATE MEDICAL-CARE, INC., a Californra-corporati~nafteyrreferred to as "PMI") and CITY OF SAN BERNARDINO, PMI GROUP #9040 (herein called "Group"), is made with reference to the following facts: WITNESSETH: A. PMI is a California corporation, organized to operate a health care service plan, re9istered under the California Knox-Keene Health Plan Act, to provide various lndividuals and Groups with health care benefits. B. Group represents that it has a bona fide list of enrollees and is authorized to enter into agreements, for health care services on their behalf. C. The parties desire by this Agreement to establish a health care program for the benefit of the enrollees of the Group, covering the following services: NOW, THEREFORE, in consideration of the mutual covenants herein contained and for other good and valuable consideration, it is agreed as follow: 1. Terms The term of this Agreement shall be from January 1, 1989, through December 31, 1989, and shall automatically be renewed for additional successive one-year terms, unless either party shall give written notice of termination to the other party at least ninety (90) days prior to the end of any such yearly term, in which event this Agreement shall be terminated at the end of such yearly term. 1 . 1 PMI shall not increase the monthly fees paid by Group, nor decrease in any manner the benefi ts stated in th is Cont ract, except after a peri od of at least thirty (30) days from and after a postage-paid mailing to Group, at Group's address of record with PMI of written notice of such proposed change. Any such change shall become effective on the anniversary date of this contract next succeeding the expiration of said notice period, unless a different effective date is agreed to by the parties. 1.2 If this Contract is renewed as provided above, the coverage of each eligible person is automatically renewed; if the Contract is not renewed, coverage of all e 1 i g i b 1 e en ro 11 ees ceases on the date the Cont ract termi nates. The 5122 Katella Avenue, Suite 206, Los Alamitos, CA 90720 (213) 493-6661, (714) 978-6624 So. California 1-800-325-4529 No. California 1-800-422-4234 Nationwide 1-800-821-2058 ('!~4#~ 41 primary enrollee may reinstate coverage in the PMI program after having previously allowed eligibility to lapse so long as this Contract remains in effect for the Group. A primary enrollee must pay all unpaid monthly fees from the time eligibility lapsed up to and including the current payment before he/she may be reinstated. 1.3 PMI sha 11 not cance 1 or dec 1 i ne to renew or rei nstate the Cont ract, nor modi fy its terms, nor sha 11 the benefi ts or coverage be subject to any limitations, exceptions, exclusions, reductions, copayments, co-insurance, deductibles, reservations, or fees, price or charge differential, because of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation or age of any employee or member of Group or any person reasonably expected to benefit from this Contract as an enrollee or otherwise. 2. Entitlement of Eligible Person Group shall provide a list of eligible enrollees each month commencing, January 1, 1989. PMI promises to Group, to provide, during the term of this Agreement, to each primary enrollee whose name appears on the eligible list, and each other eligible person in his family as defined in paragraph 3 below, all commencing on the first day of the first month as to which the primary enrollee's name so appears, and continuing so long as the primary enrollee's name continues to appear on such eligible list (but in no event beyond the term of this Agreement), and so long as the fees are paid with respect to such primary enrollee as provided in paragraph 4, page 5, the services described in Schedule A attached, subject to the limitations and exclusions described in Schedule B attached. PMI may require eligible persons to present, pri or to recei vi ng any such serv ices, reasonab 1 e proof of e 1 i g i b i 1 i ty in accordance wi th un i form procedures to be es tab 1 i shed by PMI from time to time. Group shall al so provide a monthly 1 i st of all persons electing continued coverage pursuant to Appendix A, showing their Social Security numbers, their dates of election, the number of months of continued coverage, and, if applicable, the names of the primary enrollees who previously entitled them to coverage as eligible dependents. 2.1 All benefits and services described in Schedule A shall cease as to a given primary enrollee, and other eligible persons in his family, at the end of the last period for which payment is made by Group as provided in paragraph 4, page 5, with respect to such primary enrollee, except as provided in paragraph 2.2. Notwithstanding the foregoing, a primary enrollee or other eli~ible persons may elect to continue coverage under the Continued Coverage Optlon Rider (attached hereto as Appendix A). Eligibility for such continued coverage shall continue for the period required by Appendix A. 2.2 In the event the Group ceases to exist or this Contract is terminated, or a pri mary enro 11 ee 1 eaves the Group, or otherwi se ceases to be e 1 i 9 i b 1 e for coverage, the primary enrollee nonetheless may continue his eligibility in qO~O-l.VAG 2 the plan if he/she or a family member is then in the process of receiving vision services pursuant to this Contract, until such services are completed, provided that: a. During such period the primary enrollee must maintain current payments of fees; and b. No new or additional work may be started during this temporary period. 2.3 If an eligible person is entitled under a group insurance policy or any other group health benefits program (including another PMI program) to receive or be reimbursed for the cost of vision services which are also Benefits under this program, and if the other policy or program is "primary" under the rules described in Paragraph 2.3 (a) below, then the cost of vision services rendered by non-Primary Optometrists under this program shall be reimbursed only to the extent that the vision services are Benefits and are not fully paid for or provided under the terms of the other policy or program. If this program is "primary" under those rules, Benefits shall be provided as if the other policy or program did not exist and any payment received by an Optometrist from other coverage shall be applied to any copayments due from an eligible person. a. If the other policy or program principally covers services or expenses other than vision care, this program shall be "primary." Otherwise, the determination of which policy or program is "primary" shall be governed by the following rules: 1) The policy or program covering the patient as other than a dependent shall be primary over the policy or program covering the patient as a dependent. 2) The policy or program covering a child as a dependent of a parent whose birthday occurs earlier in a calendar year shall be primary over the po 1 icy or program coveri ng a ch i 1 d as a dependent of a parent whose birthday occurs later in a calendar year (except for a dependent child whose parents are separated or divorced as described in 3) below). 3) In the case of a dependent child whose parents are legally separated or divorced: a) I f the parent wi th custody has not remarri ed, the po 1 icy or program covering the child as a dependent of the parent with custody shall be primary over the policy or program covering the child as a dependent of the parent wlthout custody. b) If the parent with custody has remarried, the policy or program covering the child as a dependent of the parent with custody shall be primary over the policy or program covering the child as a dependent of the step-parent, and the policy or program covering the child as a dependent of the step-parent shall be primary over the policy or program covering the child as a dependent of the parent without custody. c) If there is a court decree that establishes financial responsibility for vision services which are Benefits under this program, then notwithstanding 3) a) and 3) b), the policy 9040-1.VAG 3 or program coveri ng the ch i 1 d as a dependent of the parent with such financial responsibi 1 ity shall be primary over any other policy or program covering the child. 4) If the primary policy or program cannot be determined by the rules described in 1), 2) or 3), the policy or program which has covered the eligible person for the longer period of time shall be primary, wi th the fo 11 owi ng except ion: A po 1 icy or program coveri ng the eligible person as a laid-off or retired employee or the dependent of a laid-off or retired employee shall not be primary under this rule 4) over a policy or program covering the eligible person as an employee or the dependent of an employee. However, if the prov is ions of the other pol icy or program do not i nc 1 ude th is exception, which results in neither program being primary, then this exception shall not apply. b. An eligible person shall provide to PMI and PMI may release to or obtain from any insurance company or other organization, any information about the eligible person that is needed to administer this Paragraph 2.3. PMI shall, in its sole discretion, determine whether any reimbursement to an insurance company or other organi zat ion is warranted under thi s Paragraph 2.3, and any such reimbursement pa i d sha 11 be deemed to be Benefits under this Agreement. PMI shall have the right to recover from an optometrist, eligible person, insurance company or other or~anization, as PMI chooses, the amount of any Benefits paid by PMI WhlCh exceed its obligations under the terms of this Paragraph 2.3. 3. Definition of Eligible Persons El igible persons shall include all employees or members of Group, and the spouses (unless legally separated or divorced) and unmarried dependent children under nineteen (19) years of age, of such employees or members. Unmarried children who are 19 years of age or older, but less than 23 years of age, will also be considered as eligible persons if they are enrolled on a full-time basis (at least 12 units per quarter or semester) as a student in an accredited school or college and are wholly dependent upon the employee or member for ma i ntenance and support. Prov i ded, however, that a dependent chi 1d shall remain el igib1e despite attaining such 1 imiting age whl1e the child is and continues to be both (a) incapable of self-sustaining employment by reason of mental retardation or physical handicap, and (b) chiefly dependent upon the employee or member for support and maintenance, provided proof of such incapacity and dependency is furnished to PMI by the employee or member within thirty-one (31) days of the child's attainment of the limiting age and subsequently as may be required by PMI but not more frequently than annually after the two-year period following the chi 1d' s attainment of the limiting age. The word "child" includes a lawfully adopted child, and any stepchild or foster child who depends on the employee or member for ma i ntenance and support and has the same permanent res i dence as the employee or member. Dependents in military service are not eligible. Eligible persons shall also include persons ceaslng to meet the conditions of eligibility outlined above who elect continued coverage as provided in Appen- dix A (Continued Coverage Option Rider), and for whom the appropriate monthly payment specified in Paragraph 4 is received by PMI. 9040-1.VAG 4 ------l 4 . Fees The monthly fees payable to PMI hereunder per primary enrollee and eligible dependents, commencing with the month in which this Agreement becomes effective as provided in paragraph 1 above, or the pay period in which the primary enrollee becomes eligible, whichever later occurs shall be $7.68 per primary enrollee, $10.56 per primary enrollee plus one dependent and $15.36 per primary enrollee plus two or more dependents. Such fees shall be mailed to PMI at 5122 Katella Ave., Suite 206, Los Alamitos, California 90720. In addition to these fees, primary enrollees and eligible dependents are requi red to pay any copayments 1 i sted in thi s Agreement di rect ly to the participating optometrist. Fees for each person who elects continued coverage as provided in Appendix A for himself or herself only shall be the same as for a single primary enrollee. Fees for a person who also elects cont i nued coverage for hi s or her dependents sha 11 be the same as for a primary enrollee with the same number of dependents. Group may charge persons electing continued coverage pursuant to Appendix A such amounts as are permitted by Title X of P.L. 99-272. 5. Participating Optometrists The services provided for by this Agreement shall be rendered by partici- pating optometrists only, and PMI shall have no obligation or liability to eligible persons with respect to services rendered to them by non- participating optometrists. A list of participating optometrists shall be furnished to all primary enrollees and notices of revisions of such list will be mailed to primary enrollees periodically, or furnished to them on request. All services will be rendered at the office of the participating optometrist. It is understood that any participating optometrist may!rovide services to eligible persons either personally, or through associate optometrists, or other technicians, personnel or employees as may lawfully perform the particular service required. PMI agrees to provide participating optometrists during the term of this Agreement at convenient locations mutually acceptable to Group. 5.1 The primary enrollee may select any participating optometrist whose name is contained in said list at the time his eligibility begins, and may make a change to any other such participating optometrist during the thirty (30) day period before the renewal date of this Agreement. Any other change requested by a primary enrollee will be made upon thirty (30) days written notice given by the primary enrollee to PMI, and a showing by him of a confl ict between himself/herself and the optometrist previously selected. 5.2 PMI shall provide written termi nat i on or breach of participating optometrists thereby. notice within a reasonable time to Group of any Contract by, or inability to perform of, any if Group may be materially and adversely affected 9040-1.VAG 5 5.3 In the event PMI fails to pay a participating optometrist, the eligible person shall not be liable to the participating optometrist for any sums owed by PM I . In the event PMI fails to pay a non-participating optometrist, the eligible person may be liable to the non-participating optometrist for the cost of services. 5.4 Upon termination of a contract between PMI and a participating optometrist, PMI shall be liable for covered services rendered by such optometrist (other than for copayments as set forth in the Schedule of Benefits) to a primary enrollee or dependent enrollee who retained eligibility under this Contract or by operation of law under the care of such optometrist at the time of such termination unti 1 the services being rendered to the primary enrollee or dependent enrollee by such optometrist are completed, unless PMI makes reasonable and medically appropriate provisions for the assumption of such services by another participating optometrist. 6. Di sputes Any dispute or cont roversy arl s 1 ng out of or re 1 at i ng to th is Agreement, shall be resolved by arbitration as follows: Either party to the dispute (if one of the parties is an eligible person, Group, at its option, may act on behalf of such person; if one of the parties is a participating optometrist, PMI, at its option, may act on behalf of such optometrist) may commence the arbitration proceeding at any time within six (6) months after the dispute arises by written notice to the other party selecting and naming an arbitrator. Within thirty (30) days after receipt of such notice, the other party shall select and name an arbitrator and so advise the initiating party in wri t i ng. The two persons so se 1 ected sha 11 proceed to name a th i rd neutral arbitrator within sixty (60) days after notice of appointment of the second arbitrator. The Board of Arbitration shall proceed with all possible dispatch to hear and determine the dispute. It shall require the affirmative vote of two of the three members of the Board to decide the issue and the decision in all cases shall be binding upon the parties hereto. The decision shall be in writing and signed by all members of Board but shall be legal and binding when signed by a maj ori ty thereof. Each party sha 11 bear the fees and expenses of the arbitrator selected by him, but fees and expenses of the neutral arbitrator, who shall be Chairman of the Board, and stenographic expenses shall be borne equally by the parties to the dispute. The Board of Arbitration shall have no power to add to, subtract from, modi fy, or make any changes as to the terms of this Agreement. In the event the two arbitrators fail to select a third neutral arbitrator within the sixty (60) day period prescribed above, or if the parties to the dispute so agree, the matter shall instead be submitted to arbitration before the American Arbitration Association in accordance wi th its then preva i 1 i ng ru 1 es I in wh i ch case the dec is i on of the arbitrator shall be binding on the parties. In the event that suit is instituted to enforce any of the provisions of this Agreement, or the Arbitration award, the prevailing party shall be entitled to recover, in 9040-1.VAG 6 addition to any other relief which may be awarded, its reasonable attorney's fees in connection therewith. 7. Definitions As used in this Agreement, the following terms shall have the following meanings: a. "Primary enrollee," "Dependent enrollee," "Enro11ee(s)," or "E1 igib1e person" means a person who is enrolled in the PMI program, and who is a recipient of services from the PMI program. b. "Copayment" means an additional fee charged to an eligible person which is approved by the Commi ss i oner of Corporat ions, prov i ded for in th is Contract, and disclosed in the Evidence of Coverage. c. "Evidence of Coverage" means any certificate, agreement, contract, brochure, or letter of entitlement issued to a primary enrollee or eligible person setting forth the coverage to which the eligible person is entitled. d. A factor is "material" with respect to a matter if it is one to which a reasonable person would attach importance in determining the action to be taken on the matter. e. "Act" means the Knox-Keene Health Care Service Plan Act of 1975, or any successor thereto under which PMI is regulated. f. "Participating Optometrist" means an optometrist with whom PMI has an agreement to provide services to eligible persons hereunder. g. "Benefits" and "Coverage" mean the health care services available under this Contract. 8. Cancellation Enrollment of a primary or dependent enrollee or eligible person under this Agreement may be canceled, or renewal refused, by PMI only in the following events (cancellation of enrollment of a primary or dependent enrollee shall automatically cancel the enrollment of all other e1 igib1e persons in hi s family as defined in paragraph 3 above): a. Upon exp i rat i on or termi nat i on of th is Group Cont ract, if it is not renewed. b. Upon the person's ceasing to come within the definition of "Eligible Person" as set forth in paragraph 3 above. c. If the fees are not paid by or for the eligible person within fifteen (15) days. d. On thirty (30) days written notice, such cancellation to be effective at the end of the notice period: 1) If the primary enrollee is dropped by the Group from the eligible list, or ceases to be a employee or member of Group. 2) I f the pri ma ry en ro 11 ee fa i 1 s to make payments of copayment s or other charges required of him or an eligible dependent enrollee of his family hereunder; provided, however, that the primary enrollee 9040-1.VAG 7 may be reinstated during the term of this Agreement upon payment of said delinquent charges or copayments and any unpaid monthly fees. 3) If the primary or dependent enrollee or eligible person is guilty of habitual intemperance or misconduct while in the office of a participating optometrist. 4) If in the professional judgment of the optometrist who is to render service, that service cannot properly be rendered to the primary or dependent enrollee. 5) If the primary or dependent enrollee of hi s fami ly knowingly perpet rates or permi ts another person to perpet rate, fraud, or deception in the use of the services or facility of or provided by PMI. e. A primary or dependent enrollee or eligible person who alleges that his enrollment has been canceled or not renewed because of the enrollee's health status or requirements for health care services may request a review by the Commissioner of Corporations. If the Commissioner determines that a proper complaint exists under the provisions of 1365 of the Health and Safety Code, the Commissioner shall notify PMI. Within fifteen (15) days after receipt of such notice, PMI shall either request a hearing or reinstate the primary or dependent enrollee. If, after heari ng, the Commi ss i oner determi nes that the cance 11 at i on or failure to renew is contrary to subdivision (a) of Section 91365, the Commi ss i oner sha 11 order PMI to rei nstate the primary or dependent enrollee. A reinstatement pursuant to subdivision (b) of Section 1365 shall be retroactive to the time of cancellation or failure to renew and PMI shall be liable for the expenses incurred by the primary or dependent enro 11 ee for covered hea 1 th care serv ices from the date of cancellation or non-renewal to and including the date of reinstatement. f. I n the event of cance 11 at i on by PMI (except in the case of fraud or decept ion in the use of serv ices or f ac i 1 it i es of PMI or knowi ng 1 y permi tt i ng such fraud or decept i on by another) or by Group, PMI sha 11 within thirty (30) days return to Group the pro rata portion of the money paid to PMI which corresponds to any unexpired period for which payment had been received, together with amounts due on claims, if any, less any amounts due to PMI. g. Acceptance by PMI of the proper monthly fees, after termination of the Contract and without requiring a new application, shall reinstate the Contract as though it had never terminated, unless PMI shall within five (5) business days of receipt of such payment, either (1) refuse the payments s6 made, or (2) issue to Group a new Contract accompanied by written notice stating clearly those respects in which the new Contract d if fers from the termi nated Cont ract in benef its, coverage, or otherwise. 9. California Health & Safety Code PMI is subject to the requirements of Chapter 2.2 of Division 2 of the California Health & Safety Code (the "Act:) and of Subchapter 5.5 of Chapter 3 of Title 10 of the California Administrative Code (the "Regulations"), and any provision required to be in this Contract by either of the above shall bind PMI whether or not provided in this Contract. 9040-1.VAG 8 10. Group shall designate in writing a representative for purposes of receiving notices from PMI under this Contract. Group may change its representative at any time on thirty (30) days written notice to PMI. Any notice required from PMI to either Group or any eligible person may be given by PMI to the group representative, who shall disseminate such notice to prlmary enrollee and enrollees from Group by the next regular communication to such primary enrollee and enrollees but in no event, later than thirty (30) days after the receipt thereof. The )'}11jt)a"y; grQUp representative for purposes of this Contract shall be ~ ~ I N WITNESS WHEREOF, the part i es have execu(ted th is Agreement and have affi xed thei r signatures on the /scfA- day of fl)1.1~LJ , 19a. By: CITY OF SAN BERNARDINO ~ PMI GROUP #9040 ~Ti21y~ P.O. Box 1318 Address San Bernardino CA City State 714/384-5002 Telephone Number ~(IJJJ,1h /-5: /C1Jf Da e I f 92402 Zip Approved as to form and legal content: JAMES F. PENMAN City Attorney B~ 9040-I.VAG PMI By: 1~f01 ]lJ1L~~~ 1 natur an 1 ATTEST: ~~~.h ,~,~ Crerk crt4ftl 9 I CF7-(;~ g SCHEDULE A DESCRIPTION OF BENEFITS AND COPAYMENTS PROGRAM Al The following optometric services are available from a panel optometrist subject to the exclusions and governing administrative policies of the program: ENROLLEE PAYS DEDUCT I BLE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None COMPLETE EYE EXAMINATION every 12 months............................................ No Cost If examination reveals the need of glasses and the patient wishes to take the prescription elsewhere the patient pays........................................... No Cost LENSES (Glass or Plastic) if needed, every...................... .12 mos. No Cost Single Vision (Sph. & Cyl. to 4 Oio.)...................... No Cost Single Vision (Over 4 Oio.) additional per Oio............. No Cost Single Vision, Lenticular............................Cost + $ 5.00 Flat Top 25 Bifocal (Sph. & Cyl. to 4 Oio.}................ No Cost Flat Top 25 Bifocal (over 4 Oio.) additional per Oio....... No Cost Executive Bifocal (Sph. & Cyl. to 4 Oio.).................. No Cost Executive Bifocal (over 4 Oio.) additional per Oio......... No Cost Blended or no 1 ine......................................... $ 60.00 Lenticular.......................................... .Cost + $ 5.00 Trifocal (Sph. & Cyl. to 4 Oio.)........................... No Cost Trifocal (over 4 Oio.) additional per Dio.................. No Cost Executive Trifocal...................................Cost + $ 5.00 P rog re s s i ve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Co s t + $ 5 .00 Double 0 Trifocal....................................Cost + $ 5.00 Glass Tinted Lens, Single Vision (Pink, Grey3, Green3).................................... No Cost Glass Tinted Lens, Bifocal or Trifocals (Pink, Grey3, Green3).................................... No Cost 9040-1.VAG 10 Coated Lenses Solid color (glass or plastic)........................ Gradient (Qlass or plastic)...:....................... Multl-gradlent (~laSS or plastlc)..................... Anti Reflection glass)............................... Anti Reflection plastic)............................. UV 400 (ultraviolet coating).......................... Sc ratch Coat.......................................... Photogray Extra, Single Vision........................ Photogray Extra, Bifocal.............................. Photolite (plastic photogray)......................... Oversize Lenses, Single Vision (frame size 55 and over).... Oversize Lenses, Bifocal (frame size 55 and over).......... Prism per every two degrees................................ $ 10.00 $ 15.00 $ 25.00 $ 20.00 $ 35.00 $ 25.00 $ 25.00 $ 15.00 $ 25.00 $ 60.00 $ 10.00 $ 12.00 $ 4.00 $ 3.00 $ 10.00 Flat Top 28 Segs, additional............................... Flat Top 35 Segs, additional............................... FRAMES (up to $40.00 retail value) if needed, every..............12 mos. No Cost Designer...........................................UCR less $ 30.00 CONTACT LENSES Medically necessary*....................................... No Cost Hard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ 50. 00 Annual Service Policy................................. $ 15.00 Replacement per lens with Service Policy**............ $ 15.00 Replacement per lens without Service Policy**......... $ 25.00 Soft, Daily Wear........................................... $100.00 Annual Service Policy.................i............... $ 35.00 Replacement per lens with Service Policy**............ $ 35.00 Replacement per lens without Service Policy**......... $ 50.00 So f t, Tor i c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ 2 50 .00 Annual Service Policy................................. $ 65.00 Replacement per lens with Service Policy**............ $ 65.00 Replacement per lens without Service Policy**......... $125.00 Extended Wear.............................................. $150.00 Annual Service Policy................................. $ 65.00 Replacement per lens with Service Policy**............ $ 65.00 Replacement per lens without Service Policy**......... $ 75.00 Opaque Co 1 ored . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $200.00 Annual Service Policy................................. $ 65.00 Replacement per lens with Service Policy**............ $ 65.00 Replacement per lens without Service Policy**......... $100.00 9040-1.VAG 11 Gas P e rme a b 1 e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $125. 00 Annual Service Policy................................. $ 35.00 Replacement per lens with Service Policy**............ $ 35.00 Replacement per lens without Service Policy**......... $ 60.00 Follow-up Visits, first 90 days............................ No Cost Follow-up Visits, after 90 days, per visit with Service Policy............................ No Cost Follow-up Visits, after 90 days per visit without Service Policy......................... No Cost Failure to cancel appointment (24 hour prior notification)............................... $ 10.00 * Medically necessary contact lenses or subnormal vision aids are covered only when the visual acuity of the patient is not correctable to 20/70 in the better eye by use of conventional type lenses, but can be improved to 20/70 or better by the use of contact 1 enses or other subnorma 1 vis i on aids. ** App 1 i es on 1 y if ori g i na 1 contacts were made by the as signed pane 1 optometrist. Services not listed above (other than contact lenses) are available at the doctor's actual lab cost plus $5.00. Contact lenses not listed are avai 1 able at a cost of 30% less than the doctor's usual, customary and reasonable fees. REFUND POLICY All glasses are guaranteed for 90 days if factory defective or if there is a change in the prescription. If the patient cannot successfully wear contact lenses during the first 90 days, they may be exchanged (no cash refunds) for one pair of eyeglasses. After the 90 day period, no exchanges will be made. 9040-1.VAG 12 ~ SCHEDULE B EXCLUSION OF BENEFITS The following services are not Benefits under this program: 1 . 2. 3. 4. 5. 6. Orthoptics or vision training; Subnormal vision aids; Aniseikonic lenses; Medical consultations; Medical or surgical treatment of the eyes; Any condition for which benefits are receivable under any Worker's Compensation or occupational disease law, to the extent of such benefit; Eye exam; nat; ons requ; res (1) by an emp 1 oyee as a cond; t i on of emp 1 oyment, which the employer 1S required to provide by virtue of labor agreement, or (2) a government body; Replacement of lenses or frames which were furnished under this program and which have been lost, stolen or broken. Two pair of lenses in lieu of bifocals. 7. 8. 9. 9040-1.VAG 13 SCHEDULE C GOVERNING ADMINISTRATIVE POLICIES The following administrative guidelines are an integral part of this program and are consistent with the principles of accepted optometric practices: 1. Visual Analysis The visual analysis shall be available at no cost once during any 12 month period and shall include a complete case history; an external and internal eye examination for pathology or anomalies; a complete refraction; binocular coordination measurement and tests; a visual field charting, if indicated; near point visual functions analysis; a diagnosis of visual problems; a prescription of proper lenses, if indicated; a tonometry examination for all patients over the age of 18 and for younger patients based on family medical history of if indicated, and an occupational vision analysis with specific attention to the job being performed. If medical services regarding the visual health of the Enrollee are indicated, the panel optometrist shall refer the Enrollee to the medical practitioner of the Enrollee's choice. This referral is not a covered Benefit under this program and if required is at the Enrollee's expense. 2. Lenses and Frames When the visual analysis indicates the need for a correction to ensure proper visual health and welfare, lenses and frames are covered in conjunction with necessary professional services based on the Schedule of Benefits and Copayments. Included as Benefits are facial measurements; assistance in the selection of frames; procuring of proper lenses and frame; verifyin9 the accuracy of fabricated materials (finlshed glasses); a progress ViSlt or follow-up of both a professional or mechanical nature, as required; subsequent adj ustments of frames to mai nta in comfort and effi c i ency; 1 ens tests, case-hardened and drop ball tested lenses. Should a problem arise, consultation and advice are available at any time. New prescription lenses and frames are available only once during the covered period whenever the visual analysis so indicates. Prescription sunglasses are available in lieu of clear prescription glasses. 9040-1.VAG 14 APPENDIX A CONTINUED COVERAGE OPTION RIDER In consideration of the payments specified in Paragraph 4 of the Vision Health Care Agreement, and subject to all of the terms and conditions of the Agreement, PMI agrees to provide Benefits to persons who elect continued coverage pursuant to this Rider. 1. For the purposes of this Rider, each of the following shall constitute a "Qualifying Event:" a. Termination of a primary enrollee's employment with Group (other than for gross misconduct), or a reduction in the number of hours worked by the primary enrollee to less than any minimum number of hours required under Paragraph 3 of the amended Agreement. b. Death of a primary enrollee. c. Divorce or legal separation from a primary enrollee. d. A primary enrollee's becoming entitled to Medicare benefits. e. A dependent child's ceasing to meet the description of dependent child contained in Paragraph 3 of the amended Agreement. 2. Primary enrollees whose coverage under this program is terminated by reason of a Qualifying Event described in Paragraph la of this Rider may elect to continue coverage for themselves and their eligible dependents for 18 months following the month in which the Qualifying Event occurs. 3. Eligible dependents whose coverage under this program is terminated by reason of any of the Qualifyin9 Events described in Paragraph Ib through Ie of this Rider may elect to contlnue their coverage for 36 months following the month in which the Qualifying Event occurred. However, persons who elect to continue their coverage based on a Qualifying Event described in Paragraph la of this Rider, and who become entitled within the next 18 months to elect to continue coverage by reason of a Qualifying Event described in Paragraph Ib through Ie of this Rider, may elect to continue their coverage for a maximum of 36 months following the month in which the first Qualifying Event occurred. 4. Continued coverage can be elected only by notice to the Group, which must be given no later than 60 days after a termination of coverage by reason of a Qualifying Event, or within 60 days after the Eligible Person receives from the Group a notice about his or her rights to continued coverage because of the particular Qualifying Event, whichever is later. Persons for whom a Qualifying Event described in Paragraph lc or Ie occurs must report it to the Group within 60 days, or lose their right to elect continued coverage. 5. Continued coverage elected by a person under this Rider shall be effective as of the fi rst day of the month fo 11 owi ng the app 1 i cab 1 e Qua 1 i fyi ng Event descri bed in Paragraph 1 of the Ri der. However, Benefi ts sha 11 not be available to a person electing continued coverage before Group furnishes PMI with the data about such person required in Paragraph 2 of the Agreement, 9040-1.VAG 15 along with all fees then currently payable for such person as stated in Paragraph 4 of the Agreement. PMI sha 11 not, in any event, make Benefi ts available under this Rider with respect to any person for whom such i nformat i on and fees are not recei ved by PMI wi thi n 60 days after the date such person is required by law to notify Group of his or her election. 6. Cont i nued coverage for persons under thi s Ri der sha 11 be the same as the coverage for similarly situated eligible persons under the attached Agreement, and if coverage and/or Fees specified in Paragraph 4 are modified for such eligible persons, they shall also be modified in the same manner for persons having continued coverage under this Rider. 7. A person's continued coverage elected under Paragraphs 2 or 3 of this Rider shall terminate on the last day of the month in which any of the following events first occurs: a. The period of continued coverage specified in Paragraph 2 or 3 expires. This Agreement terminates. Group fails to pay Fees for the person as specified in amended Paragraph 4 of this Agreement. The person with continued coverage becomes eligible for vision benefits under another group health plan (as an employee or otherwise). The person becomes eligible for Medicare benefits. b. c. d. e. 8. Once continued coverage under this Rider is terminated, it cannot be reinstated. 9040-1.VAG 16