Minimum Essential Coverage & Limited Medical Benefit Program Enrollment Guide

Transcription

1 Minimum Essential Coverage & Limited Medical Benefit Program Enrollment Guide Minimum Essential Coverage Offered in tandem with Voluntary Limited Benefit Health Insurance Prescription Drugs Life Vision & Dental No Deductibles No Co-pays First Dollar Coverage For more information about your plan, Call the Enrollment IMPORTANT Crescent Limited Medical programs are not comprehensive major medical insurance plans. Policy forms are intended to comply fully with PART all applicable 1 state MINIMUM insurance statutes ESSENTIAL and regulations. COVERAGE Because of differing (ACA state Compliant requirements, Plan) benefits, terms and conditions may vary by state from the description according to the approved plan sponsor location and/or the insured s state of residence. Plan are underwritten by Companion Life Insurance Company of SC. Claims are administered by TCC of South Carolina. 1 P a g e

2 Patient Protection and Affordable Care Act ( PPACA ) compliance: The plan will at all times be in compliance with PPACA rules and regulations. Notes regarding the plan: This plan provides coverage for Preventive Services. Claims will be processed based upon the Billing practices of your healthcare provider. Services that are not Preventive Services as Defined by the Patient Protection and Affordable Care Act ( PPACA ) will not be covered By the plan. Network provider service payments will be based on the applicable network access agreement and non-network provider services will be paid based on the reasonable and customary amount. SCHEDULE OF BENEFITS Minimum Essential Coverage Benefits MEC PLAN Network 15 Preventive Services For Adults 100% 22 Preventive Services For Women 100% 26 Preventive Services For Children 100% PPO Network FIRST HEALTH DEDUCTIBLES Individual Family NETWORK None None COINSURANCE NETWORK Plan Pays 100% LIFETIME MAXIMUM None ANNUAL MAXIMUM None GENERAL EXCLUSIONS TO THE PLAN Covered expenses do not include and no benefits are payable for the following: 1. Charges that the participant is not legally required to pay for or charges which would not have been made if this coverage had not existed. 2. Non-network charges that are in excess of the reasonable and customary rates for the services as determined by the plan. 3. Charges for a covered person that are reimbursed, that could be reimbursed, or that could have been reimbursed as part of a clinical trial, by any public program, Such as Medicare or Medicaid, even if the person could have, but does not, elect To be covered by that public program. 4. Treatment or services provided by anyone other than a healthcare provider as Defined herein unless specifically stated in the plan. 5. Services that are not preventive services will not be covered by the plan. 6. Investigatory and experimental treatment, services, and supplies, unless provided for herein. 7. Services for the treatment of an illness or injury shall not be covered by the plan. 2 P a g e

3 18 MEC COVERED PREVENTIVE SERVICES FOR ADULTS 1. Abdominal Aortic Aneurysm one time screening for age Alcohol Misuse screening and counseling 3. Aspirin use for men ages and for women ages to prevent Cardio Vascular Disease when prescribed by a physician. 4. Blood Pressure screening for all adults 5. Cholesterol screening for all adults starting at age 50 limited to one every 5 years. 6. Colorectal Cancer screening for adults starting at age Depression screening for adults 8. Type 2 Diabetes screening for adults 9. Diet counseling for adults 10. Hepatitis B screening for adults 11. Hepatitis C screening for adults 12. Human Immunodeficiency Virus (HIV) screening for all adults 13. Immunization vaccines for adults: Hepatitis A Hepatitis B Herpes Zoster Human Papillomavirus (HPV) Influenza (Flu Shot) Measles, Mumps, Rubella Meningococcal Pneumococcal Tetanus, Diptheria, Pertussis Varicella 14. Lung Cancer screening for adults 15. Obesity screening and counseling for adults 16. Sexually Transmitted Infection (STI) prevention counseling for adults 17. Syphilis screening for all adults 18. Tobacco Use screening for all adults and cessation interventions for tobacco users 23 MEC COVERED PREVENTIVE SERVICES FOR WOMEN, INCLUDING PREGNANT WOMEN 1. Anemia screening on a routine basis for pregnant women 2. Breast Cancer Genetic Test Risk Assessment and counseling/testing (BRCA) for women 3. Breast Cancer Mammography screenings every year for women age 40 and over 4. Breast Cancer Chemoprevention counseling for women 5. Breast Cancer Preventive Medications for women 6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women. 7. Cervical Cancer screening 8. Chlamydia Infection screening 9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). Only Generic birth control prescriptions are covered by this Plan. 10. Domestic and interpersonal violence screening and counseling for all women 11. Folic Acid supplements for women who may become pregnant. 12. Gestational diabetes screening for women weeks pregnant 13. Gonorrhea screening for women 14. Hepatitis B screening for women at their first prenatal visit 15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women 16. Human Papillomavirus (HPV) DNA Test every three years for women with normal cytology results who are 30 or older 17. Osteporosis screening for women over age Rh Incompatability screening for all pregnant women and follow-up testing 3 P a g e

4 19. Sexually Transmitted Infections counseling 20. Syphilis screening 21. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users 22. Urinary tract or other infection screening for pregnant women; Bacteriuria 23. Well-woman visits to obtain recommended preventive services 26 MEC COVERED PREVENTIVE SERVICES FOR CHILDREN 1. Autism screening for children at 18 and 24 months 2. Behavioral assessments for children limited to 5 assessments up to age Blood Pressure screening 4. Cervical Dysplasia screening 5. Dental Caries prevention for children up to age 5 by the application of fluoride varnish from primary care physicians. 6. Depression screening for adolescents 7. Developmental screening for children under age 3 8. Dyslipidemia screening for children. 9. Fluoride Chemoprevention supplements for children without fluoride in their water source 10. Gonorrhea preventive medication for the eyes of all newborns 11. Hearing screening for all newborns 12. Height, Weight and Body Mass Index measurements for children 13. Hematocrit or Hemoglobin screening for children 14. Hemoglobinopathies or Sickle Cell screening for newborns 15. Human Immunodeficiency Virus (HIV) screening for adolescents 16. Hypothyroidism screening for newborns. 17. Immunization vaccines for children from birth to age doses, recommended ages, and recommended populations vary: Diptheria, Tetanus, Pertussis Haemophilus influenza type B Hepatitis A Hepatitis B Human Papillomavirus (HPV) Inactivated Poliovirus Influenza (Flu Shot) Measles, Mumps, Rubella Meningococcal Pneumococcal Rotavirus Varicella 18. Iron supplements for children up to 12 months at risk for anemia 19. Lead screening for children 20. Medical History for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, and 15 to 17 years. 21. Obesity screening and counseling 22. Oral Health risk assessment for young children up to age Phenylketonuria (PKU) screening in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents. 25. Skin Cancer behavioral counseling for young adults 26. Tuberculin testing for children For more information regarding preventive care recommendation and immunization, please visit the websites for the Centers for Disease Control and Prevention or the United States Department of Human Services: Preventive Services for Adults: Women s Health: Men s Health: Children: Immunization Schedule: 4 P a g e

5 INDEMNITY MEDICAL COVERAGE & PRESCRIPTION DRUGS BENEFIT DESCRIPTIONS MR 1 MR 3 NATIONAL PPO NETWORK First Health First Health Deductible None None Co-Insurance None None Hospital Indemnity Benefit Paid per Day of Confinement $250 $500 Number of Days allowed per Calendar Year In Patient Surgical (Flat Surgical Benefit) $200 $400 Number of times paid per Calendar Year 1 1 Anesthesia Benefit Per Day $50 $100 Physician Office Visit $50 $70 Number of Visits per Covered Person Per Calendar Year 5 5 Wellness Benefit $100 $100 Number of Visits per Calendar Year 2 2 Outpatient Surgical Benefit - Indemnity $100 $200 Anesthesia (25%) $25 $50 Outpatient Surgical Facility Benefit Paid per day $100 $200 Number of days allowed in Calendar Year 1 1 LIFE INSURANCE Life Insurance^ $10,000 $10,000 Dependent Spouse Life $1,000 $1,000 Dependent Child Life - 14 days or older $1,000 $1,000 MMP 2050 Form number for Companion s Employer Indemnity Benefit Health Insurance Policy ADDITIONAL BENEFITS MR 1 MR 3 Insured Rx Program EyeMed Standard Vision Program $10 Generic $30 Brand Name $1,200 Annual Limit $2,400 Family Limit $10 Co-pay Eye Exam Every 12 months $10 Generic $30 Brand Name $1,200 Annual Limit $2,400 Family Limit $10 Co-pay Eye Exam Every 12 months Patient Advocacy Included Included The premium rates include a charge for the Value Added Benefit Programs, Pharmacy Benefits, PPO fee and administrative services provided by ADMU Benefits. * The Value Added Benefits, except for pharmacy and vision programs, is neither underwritten nor insured by Companion Life Insurance Company. 5 P a g e

6 BENEFIT DESCRIPTIONS First Dollar Coverage No co-pays or deductibles for medical benefits. Daily In-Hospital Indemnity Benefit - If a Covered Person, while insured, is Confined in a Hospital as a result of Accident or Sickness, the Company will pay the Daily In-Hospital Indemnity Benefit amount, as shown in the Schedule, for each day of Confinement, for up to the Maximum Number of Days of Confinement, as shown in the Schedule. No benefit will be paid during any period the Covered Person is not under the regular care and attendance of a Physician. Surgical Indemnity Benefit - If a Covered Person has a covered surgery performed, the Company will pay the Surgical Indemnity Benefit amount. This amount is based on the Payment Factor amount, as shown in the Schedule of Surgical Indemnity Benefits, times the number of Surgical Procedure Units, as shown in the Schedule. If two or more procedures are performed through the same incision or operative field, payment will be made only for the procedure of the larger benefit. If more than one procedure is performed but each through separate incisions or in a separate operative field, the amount payable shall be the specified amount for the primary procedure plus 50% of the amount payable for all other surgical procedures performed. Unlisted Procedures: In addition to the procedures listed in the Schedule of Surgical Indemnity Benefits, amounts shall be payable for any other covered operations. The amounts for such procedures shall be determined by the Company in amounts consistent with those listed in the Schedule of Surgical Benefits. Anesthesia Indemnity Benefit - If the Surgical Indemnity Benefit is payable, the Company will pay the Anesthesia Indemnity Benefit amount, as shown in the Schedule, for the administration of anesthesia. Outpatient Physician Office Visit Indemnity Benefit - The Company will pay the Outpatient Physician Office Visit Indemnity Benefit, as shown in the Schedule, for a Physician office visit as a result of Sickness or Accident, not to exceed the Maximum Number of Office Visits per Calendar Year, as shown in the Schedule. Wellness Benefit - A. The company will pay the indemnity benefit shown in the schedule of benefits for an annual physical examination for the insured and his covered dependents up to the calendar year maximum shown on the schedule of benefits. These services will only be covered to the extent that the services are provided by, or under the supervision of, a single physician during the course of one (1) visit. Services include: 1. A history; 2. Physical examination; 3. X-rays; 4. Laboratory services including, but not limited to, a pap test, colorectal screening and prostate cancer screening. Outpatient Surgical Facility Indemnity Benefit - The Company will pay the Outpatient Surgical Facility Indemnity Benefit for charges made by an Outpatient Surgical facility, including a hospital ambulatory surgery center, provided the Covered Person is not admitted to the hospital, in connection with a covered outpatient surgical procedure performed on a Covered Person. Benefits will be paid for services and supplies such as the cost of the operating room, laboratory tests and X-ray examinations, including professional fees, drugs or medicines, and supplies. Life Insurance - If a Covered Person dies, the Company will pay the Death Benefit, subject to the provisions of the Policy. This benefit is shown in the Schedule. Payment will be made in one lump sum to the Beneficiary (or to the Insured in the event of a covered Dependent s death). 6 P a g e

7 CRESCENT INDEMNITY BENEFIT HEALTH PLAN LIMITATION AND EXCLUSIONS With respect to all of the benefits provided under the policy, no benefits will be payable as the result of: (a) suicide or any attempt thereat, while sane or insane. [if any covered person, sane or insane, should die by suicide within two years (one year in Colorado and North Dakota) of his or her effective date of coverage, life insurance benefits will not be payable; (in Missouri, the reference to insanity does not apply and suicide is no defense to payment under this policy where the covered person is a Missouri citizen unless the company can show that the covered person intended suicide when he or she applied for coverage, regardless of any language to the contrary in the policy.)] (b) any intentionally self-inflicted injury or sickness; (c) rest care or rehabilitative care and treatment; (d) cosmetic surgery or care or treatment solely for cosmetic purposes, or complications therefrom. This exclusion does not apply to cosmetic surgery resulting from a covered accident if initial treatment of the covered person is begun within 12 months of the date of the accident; (e)immunization shots and routine examinations such as: health exams; periodic check-ups; pre-marital exams; and routine physicals; (f) routine newborn care, including routine nursery charges; (g) voluntary abortion, except with respect to the insured or covered dependent spouse: (1)where such person s life would be endangered if the fetus were carried to term; or (2)where medical complications have arisen from an abortion; (h) pregnancy of a dependent child, unless required by law; (i) the treatment of: (1)mental illness; (2)functional or organic nervous disorder, regardless of cause; (3)alcohol abuse; (4)drug use, unless such drugs were taken on the advice of a physician and taken as prescribed, for more than 10 days in any calendar year, with respect to payment of the daily in-hospital indemnity benefit; (j) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (k) committing, attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation; (l) participation in a contest of speed in power driven vehicles, parachuting, parasailing, bungee-jumping, or hang gliding; (m) air travel, except: (1)as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2)as a passenger for transportation only and not as a pilot or crew member; (n) any accident occurring as a result of the covered person being intoxicated (where the blood alcohol content meets the legal presumption of intoxication under the law of the state where the accident took place); (o) sex changes; (p) experimental treatments or surgery; (q) the reversal of tubal ligation and vasectomies; (r)artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications, or physician s services, unless required by law; (s) treatment of exogenous obesity or weight control; (t)an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization. This exclusion includes accident sustained or sickness contracted while in the service of any military, naval or air force of any country engaged in war. The company will refund the pro rata unearned premium for any such period the covered person is not covered; (u) accident or sickness arising out of and in the course of any occupation for compensation, wage or profit. Expenses which are payable under occupational disease law or similar law, whether or not application for such benefits has been made; (v) pre-existing conditions, except as described in the schedule; or (w)air or ground ambulance service. (x) for loss incurred, care or treatment received, or hospital confinement occurring outside of the United States or its possessions. In addition to the exclusions and limitations for all coverages, the following are not covered under the out-patient physician office visit indemnity benefit and the outpatient diagnostic x-ray and laboratory indemnity benefit: (a) visits made, examinations given, or x-rays or laboratory tests performed as an in-patient while confined to a hospital; (b) routine eye examinations or fitting of glasses; (c) fitting of hearing aids; (d) dental examinations or dental care other than expenses resulting from accidental injury; and (e)benefits which are provided under any other part of the policy. 7 P a g e

8 VALUE ADDED BENEFIT PROGRAMS The Value Added Benefit Programs is neither underwritten nor insured by Companion Life Insurance Company. Companion assumes no responsibility or liability for any of the listed services, the providers of the services, the quality of the services, the delivery of the services or the outcomes of the services. Questions or concerns about the services should be addressed directly to the providers. PRESCRIPTION DRUG COVERAGE ADVANTAGE RX 10/30 PLAN $10 Co-pay for Preferred Generic drugs $30 Co-pay for Preferred Brand Name $100 individual monthly - $200 family monthly max. VISION BY DESIGN Vision Essentials ($10 Co-pay Eye Exam + Discount). Provides a paid in full exam and substantial point of sale discounts for frames, lenses and contact lenses. Discount applies when a complete pair of eyeglasses ** is purchased; otherwise the discount is 20% off the retail price. Members also receive a 40% discount off complete pair of eyeglass purchases (frames, lenses, and lens options purchased in the same transaction) and a 15% discount off conventional contact lenses once the funded benefits have been used. After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member. Details are available at The contact lens benefit allowance is not applicable to this service. Laser vision correction (Lasik or PRK) savings of 15%off retail or 5%off promotional price nationwide.* PATIENT ADVOCACY Your medical program includes a service called Patient Advocacy provided by The Karis Group, which can provide tremendous help and reassurance when members faced with large medical bills. This service links members to negotiating professionals who help them resolve their bills with medical providers, whether in or outside of the network or whether it s after one has been scheduled for admission or once a member has a bill in hand. NOT AN INSURANCE PRODUCT. 8 P a g e

9 MEC FREQUENTLY ASKED QUESTIONS Q: New MEC plans, why have I not heard about this before. A: HHS just released the regulations in late 2012, thus it took time to review the regulations. Q. If I receive my coverage from my spouse s employer, will I have minimum essential coverage? A: Yes. Employer-sponsored coverage is generally minimum essential coverage. If an employee enrolls in employersponsored coverage for himself and his family, the employee and all of the covered family members have minimum essential coverage. Q. Do my spouse and dependent children have to be covered under the same policy or plan that covers me? A: No. You, your spouse and your dependent children do not have to be covered under the same policy or plan. However, you, your spouse and each dependent child for whom you may claim a personal exemption on your federal income tax return must have minimum essential coverage or qualify for an exemption, or you will owe a payment when you file. Q: What happens if I do not have minimum essential coverage, and I cannot afford to make the payment with my tax return? A: The IRS routinely works with taxpayers who owe amounts they cannot afford to pay. The law prohibits the IRS from using liens or levies to collect any payment you owe related to the individual responsibility provision, if you, your spouse or a dependent included on your tax return does not have minimum essential coverage. INDEMNITY MEDICAL FREQUENTLY ASKED QUESTIONS Q: Are pre-existing conditions covered by the Limited Benefit Health Insurance? A: Yes, pre-existing conditions are covered. Q: How does my medical plan work? A: The plan you have been issued is called a Limited Benefit Health Insurance plan. This is NOT MAJOR MEDICAL INSURANCE; nor is it intended to replace major medical insurance. The limited benefit health insurance plan pays a scheduled amount for various medical services. When a claim is filed, 100% of the indemnity amount for the medical service provided is paid based upon the schedule of benefits of your plan. For example, if your plan specifies an indemnity amount of $75 for a doctor s office visit, your benefits plan will pay the service provider $75 toward the billed amount (or you will be reimbursed $75 if you file your own claim). Your plan also has the benefit of a Preferred Provider Organization (PPO). Q: Is this Major Medical Insurance? A: No. Limited Benefit Health Insurance plans offer limited benefit medical reimbursement coverage for basic medical expenses at an affordable cost. Unlike major medical, these plans do not coordinate benefits, so it pays regardless of any other coverage the covered person may have. Q: If my doctor is not listed as a PPO provider, will that change the benefit I will receive? A: No. the plan will pay the same benefits in your schedule of benefits whether you go to a PPO provider or a Non-PPO provider. You are free to use any licensed provider or hospital of your choice. If you go to a participating PPO provider, chances are your benefits will go further and cover more of the bill. Q: Why should I use a PPO Provider? A: By utilizing an in-network provider, you may reduce your out-of-pocket expense because the PPO provider will charge a negotiated reduced fee for his / her service. Q: Do these plans cover Maternity? A: Yes. Maternity is covered the same as any other sickness benefit and will pay subject to the limits of the plan chosen. Q: What is my co-payment amount? Is there a deductible? A: One of the great features of your limited benefit health insurance plan is that there are NO deductibles or co-payments. 9 P a g e

10 Advantage Dental PLAN DESCRIPTION This plan pays 100% coverage of allowable charges for Preventive services, 80% coverage for Basic services and 50% coverage for certain Major services after a combined $100 lifetime deductible (all covered services). This is a PLAN YEAR policy (not calendar year). Open network choose any dentist. FEATURES: ANNUAL MAXIMUM - $1,000 per person PREVENTIVE SERVICES Paid at 100%: Routine exams and cleanings (one per 12 months) Fluoride treatment for children under age 19 (one per 12 months) Bitewing X-rays (one per 12 months) Emergency treatment for dental plan (minor procedures) BASIC SERVICES Paid at 80%: (6 month waiting period) Simple restorative services (fillings) Sealants for children ages 6 through 15 (one per tooth per 36 months) MAJOR SERVICES Paid at 50%: (12 month waiting period) Endodontics (includes root canals) Periodontics Teeth removal and other oral surgery Medically appropriate anesthesia related to covered surgery X-rays of the roots of teeth X-rays (Full mouth or Panorex, one per 36 months) Space maintainers MAJOR SERVICES NOT COVERED: Dentures, bridges, inlays, onlays and all associated charges Crowns, except associated with root canal procedure performed while covered under this plan No Orthodontic coverage This is a general outline of covered benefits and does not include all the benefits, limitations, and exclusions of the policy. Please see certificate for details. Plans are underwritten by Companion Life Insurance Company of South Carolina. Plan marketed by ADMU Benefits, LLC. 10 P a g e

11 Vision Select Program Vision by Design PLAN DESCRIPTION What is Vision by Design? It's a managed vision care program combining unlimited choice with high quality and significant value. Vision by Design is underwritten by Companion Life Insurance Company. The provider network, customer service and claim administration is through EyeMed Vision Care. FEATURES: Access To More Than 35,000 Vision Care Providers At 18,000 Convenient Locations Nationwide Evening And Weekend Hours At Many Locations Choice Of Thousands Of Fashionable, Designer Frames No Appointment Necessary, And Service In About An Hour In Most Locations EXTENSIVE PROVIDER NETWORK Unlike other programs that may restrict provider options, Vision by Design offers a nationwide network of convenient, accessible options for eye care. Companion Life, in association with EyeMed Vision Care, offers easy access to thousands of conveniently located vision care providers including optometrists, ophthamologists, opticians and many leading optical retailers, such as LensCrafters, Target Optical, and most Sears Optical, and Pearl Vision, locations. Quality Vision Care EyeMed has a firm commitment to quality and patient satisfaction. All EyeMed Vision Care providers must meet NCQA credentialing standards. Providers are monitored through EyeMed's Quality Assurance Program and recredentialing process. Quality Products Vision by Design members have unlimited choice of available eyewear products. Our members are free to select from any available frame including designer frames by Luxottica, such as Vogue, Brooks Brothers, Anne Klein, and many more. Superior Value Members enjoy savings of up to 40% off retail prices, with continued savings after the initial benefits have been used. Service Excellence EyeMed focuses on delivering service excellence throughout all areas of program administration, featuring call center representatives available seven days a week, including evenings. They combine innovative solutions with the most current technology to enhance the administrative experience for both clients and members. 11 P a g e

12 Vision Care Services Exam with Dilation (as necessary): In Network Out-of-Network $10 Copay $35 allowance Contact Lens fit and Follow-up: (Contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed) Standard Premium* $0 Copay $40 allowance $0 Copay, $40 allowance 10% off retail, then apply $55 allowance Frames: Any available frame at provider location In Network Out-of-Network $100 frame $45 allowance allowance; 20% off balance over allowance. Standard Plastic Lenses: Lens Options: UV Coating Tint (Solid and Gradient) Standard Scratch Resistant Coating Standard Polycarbonate Standard Anti-Reflective Coating Standard Progressive (Add-on to Bifocal) Other Add-Ons and Services Contact Lenses: (Material only) Medically Necessary Frequency: Examination Frame Lenses or Contact Lenses Single Bifocal Trifocal In Network Out-of-Network $10 Copay $25 $10 Copay $40 $10 Copay $55 In Network Out-of-Network Member Pays: $15 Discount available $15 only at Network $15 providers and retailers $40 $45 $65 20% off retail Conventional and Disposable: In Network Out-of-Network $0 Copay $64 allowance $80 allowance 15% off balance over allowance (conventional only). Paid in full. $200 allowance 12 months** 24 months** 12 months** *Premium Contact Lens Fitting -all lens designs, materials and specialty fittings other than Standard (ex.: toric, multifocal, etc.) **Once in a 12 month period defined by last date of service. (Contact Lenses are in Lieu of EyeGlass Lenses) Plans are underwritten by Companion Life Insurance Company of South Carolina. Plan marketed by ADMU Benefits, LLC. 12 P a g e

13 Companion Life's Vision by Design Additional Discounts: Members will receive a 20% discount on items not covered by the plan at network Providers, which may not be combined with any other discounts or promotional offers, and the discount does not apply to EyeMed Provider's professional services, or contact lenses. Retail prices may vary by location. Members also receive a 40% discount off complete pair of eyeglass purchases (frames, lenses, and lens options purchased in the same transaction) and a 15% discount off conventional contact lenses once the funded benefits have been used. After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member. Details are available at The contact lens benefit allowance is not applicable to this service. Laser vision correction (Lasik or PRK) savings of 15% off retail or 5% off promotional price nationwide.* Plan Limitations/Exclusions: Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing. Aniseikonic lenses Medical and/or surgical treatment of the eye, eyes, or supporting structures Corrective eyewear required by an employer as a condition of employment, and safety eyewear unless specifically covered under plan Services provided as a result of any Workers Compensation law Plano non-prescription lenses and non-prescription sunglasses (except 20% discount) Services or materials provided by any other group benefit providing for vision care Two pair of glasses in lieu of bifocals Benefit is not available on those frames where the manufacturer prohibits a discount Overview: Vision Select (Exam + Eyewear + Discount) A comprehensive plan providing members with a paid in full exam, contact lens fitting and follow up, and materials. Plan includes a fully funded contact lens benefit, and additional savings of 40% off a complete pair of eyeglasses and 15% off conventional contact lenses once the funded benefit has been used. Out of network reimbursements are available. Lenses Providers are given the freedom to recommend whichever lens brands or options they believe offer the best ocular clarity. They are also free to choose any fabrication laboratory, assuring quality service and convenience. Frames Vision by Design provides total flexibility to choose eyeglass frames that meet any taste, need, or lifestyle. You may choose from any frame available at your provider location. Most providers carry frames by Luxottica, the world leader in eyeglass design and manufacturing. The Luxottica collection of eyewear includes the most reputable and prestigious names in the optical fashion world. Vision Select includes Out of Network benefits. Out of Network claim forms may be obtained by printing a copy from the EyeMed web site or by calling EyeMed's Customer Care Center. Simply pay in full at the time of service and then submit the claim form and receipts to EyeMed for reimbursement. *Since Lasik or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available from a provider in your immediate location. For a location near you and the discount authorization, please call 18775LASER6. **Complete pair of eyeglasses: frames, lenses, and lens options purchased in the same transaction. This proposal contains only a brief description of the benefits. It is not the contract. Rates and provisions are subject to change. Actual coverage is subject to the terms and conditions of the contract when it becomes effective, and actual contract language will be reflected in each employee's Certificate of Coverage. 13 P a g e

14 WEEKLY PRICING PLAN SELECTION: PER PAY PERIOD (52) RATES ILLUSTRATED MEC * MR 1** MR 3** DENTAL VISION $ IND $ IND $ IND $ IND $ IND $ IND+SP $ IND+SP $ IND+SP $ IND+SP $ IND+SP $ IND+CH $ IND+CH $ IND+CH $ IND+CH $ IND+CH $ FAMILY $ FAMILY $ FAMILY $ FAMILY $ FAMILY * The MEC Plan is the only plan option that is ACA compliant and avoids tax penalties. **MR 1 AND MR 3 Do not include any Minimum Essential Benefits. 14 P a g e