Group Vision Care Plan

	Vision Care for Life

Group Name:	THERMOCOAX, INC.
Group Number:	30019805
Effective Date:	APRIL 1, 2022	

EVIDENCE OF COVERAGE

Provided by:

VISION SERVICE PLAN INSURANCE COMPANY
3333 Quality Drive, Rancho Cordova, CA  95670
(916) 851-5000   (800) 877-7195

EOC 1002 - GA    	05/14/22 Eop	

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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:
NAME OF PLAN:
PRINCIPAL ADDRESS:

EMPLOYER I.D.#:

GROUP #:

PLAN ADMINISTRATOR:
ADDRESS:

PHONE NUMBER:

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

ADDRESS:

Benefits are furnished under a vision care Policy purchased by the Group and provided by VISION SERVICE PLAN INSURANCE COMPANY (VSP) under which VSP is financially responsible for the payment of claims.

This Evidence of Coverage is a summary of the Policy provisions and is presented as a matter of general information only. It is not a substitute for the provisions of the Policy itself. In the event of any dispute between this Evidence of Coverage and the Policy, the provisions of the Policy will prevail. A copy of the Policy will be furnished on request.

DEFINITIONS:

ADDITIONAL BENEFITS RIDER	The document attached as Exhibit C to the Group Policy maintained by your Group Administrator, which lists selected vision care services and vision care materials that a Covered Person is entitled to receive by virtue of the Plan.	
		
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.	
		
COORDINATION OF BENEFITS	Procedure that allows more than one insurance plan to consider Covered Person's vision care claims for payment or reimbursement.	
		
COPAYMENTS	Those amounts required to be paid by or on behalf of a Covered Person for Plan Benefits which are not fully covered, and which are payable at the time services are rendered or materials provided.	
		
COVERED PERSON	An Enrollee or Eligible Dependent who meets VSP’s eligibility criteria and on whose behalf premiums have been paid to VSP, and who is covered under the Policy.	
		
ELIGIBLE DEPENDENT	Any legal dependent of an Enrollee of Group who meets the eligibility criteria established by Group and approved by VSP under Section VI. ELIGIBILITY FOR COVERAGE of the Policy under which such Enrollee is covered.	
		
EMERGENCY CONDITION	A condition, with sudden onset and acute symptoms, that requires the Covered Person to obtain immediate medical care, or an unforeseen occurrence requiring immediate, non-medical action.	
		
ENROLLEE	An employee or member of the Group who meets the eligibility criteria specified under Section VI. ELIGIBILITY FOR COVERAGE of the Policy.	

EXPERIMENTAL NATURE	A procedure or lens that is neither used universally nor accepted by the vision care profession, as determined by VSP.	
		
GROUP	An employer or other entity that contracts with VSP for coverage under this Policy in order to provide vision care coverage to its Enrollees and their Eligible Dependents.	

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VSP NETWORK 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-VSP PROVIDER	An 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 or PLAN BENEFITS	The vision care services and vision care materials that a Covered Person is entitled to receive by virtue of coverage under the Policy, as defined on the attached Schedule of Benefits and Additional Benefit Rider (if applicable).	
		
POLICY	The contract between VSP and Group upon which this Plan is based.	
		
PREMIUMS	The Payments made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits, as stated in the Schedule of Premiums attached as Exhibit B to the Group Policy document maintained by your Group Administrator.	
		
RENEWAL DATE	The date on which the Policy shall renew or terminate if proper notice is given.	
		
SCHEDULE OF BENEFITS	The document attached as Exhibit A to the Group Policy maintained by your Group Administrator, that lists the vision care services and vision care materials that a Covered Person is entitled to receive by virtue of the Plan.	
		
SCHEDULE OF PREMIUMS	The document attached as Exhibit B to the Group Policy maintained by your Group Administrator, which states the payments to be made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits.	
		
ELIGIBILITY FOR COVERAGE
Enrollees:  To be covered, a person must currently be an employee or member of the Group and meet the established coverage criteria mutually agreed upon by Group and VSP.

Eligible Dependents:  If dependent coverage is provided, the persons eligible are indicated on the attached Schedule of Benefits and Additional Benefit Rider (if applicable).

PREMIUMS
Group is responsible for payments of the periodic charges for coverage. Group will notify Covered Person of Covered Person's share of the charges, if any. The entire cost of the program is paid to VSP by Group.

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PROCEDURE FOR USING THE PLAN
1.	When Covered Person wants to receive Plan Benefits, contact VSP or a VSP Network Doctor.  A list of names, addresses and phone numbers of VSP Network Doctors in Covered Person’s area can be obtained from Group, the Plan Administrator or VSP.  If this list does not cover the area in which Covered Person desires to seek services, call or write the VSP office nearest Covered Person to find one that does.

2.	If Covered Person is eligible for Plan Benefits, VSP will provide Benefit Authorization directly to the VSP Network Doctor. If Covered Person contacts the VSP Network Doctor directly, Covered Person must identify him or herself as a VSP member so the doctor can obtain Benefit Authorization from VSP.

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

4.	Covered Person pays the Copayment (if any) amounts that exceed the Plan Allowances and any amounts for non-covered services or materials to the VSP Network Doctor for services under this Policy. VSP will pay the VSP Network Doctor directly according to its agreement with the doctor.

Note:  If Covered Person is eligible for and obtains Plan Benefits from an Non-VSP Provider, Covered Person should pay the provider’s full fee. Covered Person will be reimbursed by VSP in accordance with the Non-VSP Provider reimbursement schedule shown on the enclosed Schedule of Benefits and Additional Benefit Rider (if applicable), less any applicable Copayments.

WARNING:  LIMITED BENEFITS WILL BE PAID WHEN NON-VSP PROVIDERS ARE USED.

Covered Persons should be aware that when they elect to utilize the services of an Non-VSP Provider for a covered service in non-emergency situations, benefit payments for services from such Non-VSP Providers are not based upon the amount billed.  The basis of the benefit payment will be determined according to the Plan's Non-VSP Provider fee schedule.  

COVERED PERSONS CAN EXPECT TO BE LIABLE FOR MORE THAN THE COPAYMENT AMOUNT DEFINED IN THE ATTACHED SCHEDULE OF BENEFITS OR ADDITIONAL BENEFIT RIDER (if applicable) AFTER THE PLAN HAS PAID ITS REQUIRED PORTION.  

When payment is made to the Non-VSP Provider, the provider may bill Covered Person for any amount up to the billed charge after the Plan has paid its portion of the bill.  VSP Network Doctors have agreed to accept discounted payments for services with no additional billing to the Covered Person other than copayments, co-insurance and non-covered services or materials.  Covered Persons may obtain further information about the participating status of providers and information on out-of-pocket expenses through vsp.com, or by calling VSP's Customer Service Department at 1-800-877-7195.

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 VSP Network Doctor (or Non-VSP Provider if the attached Schedule of Benefits and, if applicable, Additional Benefits Rider, indicates Covered Person's Plan includes such coverage). No prior authorization 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 Supplemental Primary EyeCare Plans. If there is no Additional Benefit Rider for one of these plans attached to this Evidence of Coverage, 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 VSP Network Doctors will be made in accordance with their agreement with VSP.

6.	In the event of termination of a VSP Network Doctor’s membership in VSP, VSP will be liable to the VSP Network Doctor for services rendered to Covered Person at the time of termination and permit the VSP Network Doctor to continue to provide Covered Person with Plan Benefits until the services are completed, or until VSP makes reasonable and appropriate arrangements for the provision of such services by another VSP Network 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 and Additional Benefit Rider (if applicable) for a summary of the level of coverage provided to Covered Person by Group. 

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BENEFITS AND COVERAGES
Through its VSP Network Doctors, VSP provides Plan Benefits to Covered Persons, subject to the limitations, exclusions and Copayment(s) described herein. When Covered Person wishes to obtain Plan Benefits from a VSP Network Doctor, Covered Person may contact any VSP Network Doctor, identify Covered Person as a VSP member and schedule an appointment. If Covered Person is eligible for Plan Benefits, VSP will provide Benefit Authorization for Covered Person directly to the VSP Network Doctor prior to Covered Person's appointment.

Specific benefits for which Covered Person is covered are described on the attached Schedule of Benefits and Additional Benefit Rider (if applicable).

COPAYMENT
The benefits described herein are available to Covered Person subject to Covered Person's payment of any applicable Copayments as described in this Evidence of Coverage, the Schedule of Benefits and Additional Benefit Riders (if applicable). Amounts that exceed plan allowances, annual maximum benefits, options reimbursements, or any other stated Plan limitations are not considered Copayments but are also the responsibility of the Covered Person. 

ANY ADDITIONAL CARE, SERVICE AND/OR MATERIALS NOT COVERED BY THIS PLAN MAY BE ARRANGED BETWEEN COVERED PERSON AND THE DOCTOR. 

COORDINATION OF BENEFITS
Covered Persons who are covered under two or more insurance plans that include vision care benefits may be eligible for Coordination of Benefits ("COB"). VSP will combine other insurance plans' claim payments or reimbursements, if any, with benefits available under Covered Person's VSP plan, which may reduce or eliminate Covered Person's out-of-pocket expense. Covered Persons covered under more than one VSP plan may also be able to take advantage of COB. In order to process claims involving COB, VSP may need to share personal information regarding Covered Persons with other parties (such as another insurance company). When this is necessary, VSP will only share such information with those persons or organizations having a legitimate interest in that information and only where such sharing is not prohibited by law.

EXCLUSIONS AND LIMITATIONS OF BENEFITS
This vision service plan is designed to cover visual needs rather than cosmetic materials. Some professional services and/or materials are not covered under this Plan. Please refer to the NOT COVERED section of the attached Schedule of Benefits and Additional Benefit Rider (if applicable) for details.

VSP may, at its discretion, waive any of the Plan limitations if, in the opinion of our Optometric Consultants, this is necessary for the visual welfare of the Covered Person.

LIABILITY IN EVENT OF NON-PAYMENT 
IN THE EVENT VSP FAILS TO PAY THE PROVIDER, COVERED PERSON SHALL NOT BE HELD LIABLE FOR ANY SUMS OWED BY VSP OTHER THAN THOSE NOT COVERED BY THE PLAN.

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 in writing by using the complaint form that may be obtained upon request from the Customer Service Department. Complaints and grievances include disagreements regarding access to care, or the quality of care, treatment or service. Covered Persons also have the right to submit written comments or supporting documentation concerning a complaint or grievance to assist in VSP’s review. VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special circumstances require an extension of time. In that case, resolution shall be achieved as soon as possible, but no later than one hundred twenty (120) days after VSP’s receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved within thirty (30) days, a letter will be sent to the Covered Person to indicate VSP’s expected resolution date. Upon final resolution, the Covered Person will be notified of the outcome in writing.

CLAIM PAYMENTS AND DENIALS
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.

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 

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

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

When Covered Person has completed all appeals mandated by the Employee Retirement Income Security Act of 1974 (“ERISA”), additional voluntary alternative dispute resolution options may be available, including mediation and arbitration.  Covered Person should contact the U. S. Department of Labor or the state insurance regulatory agency for details.  Additionally, under ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1132(a)(1)(B)], Covered Person has the right to bring a civil (court) action when all available levels of review of denied claims, including the appeals process, have been completed, the claims were not approved in whole or in part, and Covered Person disagrees with the outcome.

TERMINATION OF BENEFITS
After the Policy Term, this Policy will continue on a month to month basis or until terminated by either party giving the other party sixty (60) days notice. Policy Benefits will cease on the date of cancellation of this Policy whether the cancellation is by your Group or by VSP due to nonpayment of Premium.

If Covered Person is receiving service as of the termination date of the Policy, such service shall be continued to completion, but in no event beyond six (6) months after the termination date of the Policy.

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

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 his 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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EXHIBIT A

SCHEDULE OF BENEFITS
SIGNATURE PLAN

GENERAL
This Schedule lists the vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY ("VSP") are entitled, subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Non-VSP Provider services, as indicated by the reimbursement provisions below, vision care benefits may be received from any licensed eye care provider whether VSP Network Doctors or Non-VSP Providers. This Schedule forms a part of the Policy or Evidence of Coverage to which it is attached.

When Plan Benefits are received from VSP Network Doctors, benefits appearing in the VSP Network Doctor Benefit column below are applicable subject to any applicable Copayments and other conditions, limitations and/or exclusions as stated below. When Plan Benefits are received from Non-VSP Providers, the Covered Person is reimbursed for such benefits according to the schedule in the Non-VSP Provider Benefit column below, less any applicable Copayment. The Covered Person pays the provider the full fee at the time of service and submits an itemized bill to VSP for reimbursement. Discounts do not apply for vision care benefits obtained from Non-VSP Providers. 

ELIGIBILITY
The following are Covered Persons under this Policy:

•	Enrollee.
•	The legal spouse of Enrollee.
•	Any unmarried 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.

Unmarried dependent children are covered up to the end of the year in which they turn age 19 or up to the end of the month in which they turn age 23 if full-time students.

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:

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

There shall be a Copayment of $20.00 for the examination payable by the Covered Person to the VSP Network Doctor or the Non-VSP Provider at the time services are rendered. If materials (lenses, frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered. The Copayment shall not apply to Elective Contact Lenses.

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PLAN BENEFITS
	
SERVICE OR MATERIAL	VSP NETWORK DOCTOR BENEFIT	NON-VSP PROVIDER BENEFIT	FREQUENCY	

Eye Examination
	
Covered in full*	
Up to $  50.00*	
Available once each 12 months**	
Complete initial vision analysis:  includes appropriate examination of visual functions and prescription of corrective eyewear where indicated.

*Less any applicable Copayment.
**Beginning with the first date of service.	

SERVICE OR MATERIAL	VSP NETWORK DOCTOR BENEFIT	NON-VSP PROVIDER BENEFIT	FREQUENCY	

LENSES		
Available once each 12 months**
	
Single Vision	Covered in full *
	Up to $  50.00*		
Bifocal	Covered in full *	Up to $  75.00*
		
Trifocal	Covered in full *	Up to $ 100.00*
		
Lenticular	Covered in full *	Up to $ 125.00*
		
Plan Benefits for lenses are per complete set, not per lens.

Polycarbonate lenses are covered in full for dependent children up to the end of the month in which they turn age 19.

Standard Progressive Lenses covered in full.

*Less any applicable Copayment.
**Beginning with the first date of service.	

SERVICE OR MATERIAL	VSP NETWORK DOCTOR BENEFIT	NON-VSP PROVIDER BENEFIT	FREQUENCY	

LENS OPTIONS			
Available once each 12 months**
	
Tinted/Photochromic	Covered in full	Up to $    .00		

** Beginning with the first date of service.	

SERVICE OR MATERIAL	VSP NETWORK DOCTOR BENEFIT	NON-VSP PROVIDER BENEFIT	FREQUENCY	

FRAMES
	
Covered up to Plan Allowance*	
Up to $  70.00*	
Available once each 12 months**
	
Benefits for lenses and frames include reimbursement for the following necessary professional services:	
1.
2.
3.
4.
5.
6.	Prescribing and ordering proper lenses;
Assisting in frame selection;
Verifying accuracy of finished lenses;
Proper fitting and adjustments of frames;
Subsequent adjustments to frames to maintain comfort and efficiency;
Progress or follow-up work as necessary.	

*Less any applicable Copayment.  
**Beginning with the first date of service.
Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients.	

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SERVICE OR MATERIAL	VSP NETWORK DOCTOR BENEFIT	NON-VSP PROVIDER BENEFIT	FREQUENCY	

CONTACT LENSES

Necessary		Available once each 12 months**	
Professional Fees/Materials
	Covered in full*
	Up to $  210.00*
		
Elective	Elective Contact Lens fitting and evaluation*** services are covered in full once every 12 months**, after a maximum $60.00 Copayment.		Available once each 12 months**	
	Materials
Up to $  140.00
	Professional Fees/Materials
Up to $  105.00
		
*Less any applicable Copayment.
**Beginning with the first date of service.
***15% Discount applies to VSP Network Doctor’s usual and customary professional fees for contact lens evaluation and fitting.

Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's VSP Network Doctor or Non-VSP Provider.  Review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses.	
Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
When contact lenses are obtained, the Covered Person shall not be eligible for lenses again for 12 months and frames for 12 months.

SERVICE OR MATERIAL	VSP NETWORK DOCTOR BENEFIT	NON-VSP PROVIDER BENEFIT	FREQUENCY	
LOW VISION
				
Professional services for severe visual problems not correctable 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 amount 
up to $1000.00*	75% of amount
up to $1000.00*	*	

*Maximum benefit for all Low Vision services and materials is $1000.00  every two (2) years.

Low Vision benefits secured from Non-VSP Providers (if covered) are subject to the same time and Copayment provisions described above for VSP Network Doctors. The Covered Person should pay the Non-VSP Provider’s full fee at the time of service. Covered Person will be reimbursed an amount not to exceed what VSP would pay a VSP Network Doctor for the same services and/or materials.

THERE IS NO ASSURANCE THAT THE AMOUNT REIMBURSED WILL COVER 75% OF THE PROVIDER’S FULL FEE.	

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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 Network Doctor or by calling VSP’s Customer Care Division at (800) 877-7195.

PATIENT OPTIONS

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

•	Optional cosmetic processes.
•	Anti-reflective coating.
•	Color coating.
•	Mirror coating.
•	Scratch coating.
•	Blended lenses.
•	Cosmetic lenses.
•	Laminated lenses.
•	Oversize lenses.
•	Polycarbonate lenses.
•	Progressive multifocal lenses.
•	UV (ultraviolet) protected lenses.
•	Certain limitations on low vision care.

NOT COVERED

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

•	Orthoptics or vision training and any associated supplemental testing.
•	Plano lenses (less than a ± .50 diopter power).
•	Two pair of glasses in lieu of bifocals.
•	Replacement of lenses and frames furnished under this Policy that 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.
•	Services and/or materials not indicated on this Schedule as covered Plan Benefits.

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EXHIBIT C

ADDITIONAL BENEFIT RIDER
SUPPLEMENTAL PRIMARY EYECARE PLAN

This Rider lists additional vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY ("VSP") are entitled, subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein.  The Supplemental Primary Eyecare Plan is designed for the detection, treatment, and management of ocular conditions and/or systemic conditions which produce ocular or visual symptoms.  Under the plan, Eyecare Professionals provide treatment and management of urgent and follow-up services.  Primary Eyecare also involves management of conditions that require monitoring to prevent future vision loss.  This Rider forms a part of the Policy and Evidence of Coverage to which it is attached.

ELIGIBILITY

The following are Covered Persons under this Plan, pursuant to eligibility criteria established by Client:

•	Enrollee.
•	Legal spouse of Enrollee.
•	Any unmarried 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.

Unmarried dependent children are covered up to the end of the month in which they attain the age of 19 years, or up to the end of the month in which they attain the age of 23 years if full-time students.

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.

Plan Benefits under the Supplemental Primary Eyecare Plan are available to Covered Persons only after all other benefits under their group medical plan have been exhausted, or when Covered Person is not covered under a group medical plan.

Covered Persons with the following symptoms and/or conditions (see DEFINITIONS below) will be covered for certain primary eyecare services in accordance with the optometric scope of licensure in the Eyecare Professional’s state.

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SYMPTOMS

Examples of symptoms which may result in a Covered Person seeking services on an urgent basis under the PEC Plan may include, but are not limited to:

•	Ocular discomfort or pain	•	Recent onset of eye muscle dysfunction	
•	Transient loss of vision	•	Ocular foreign body sensation	
•	Flashes or floaters	•	Pain in or around the eyes	
•	Ocular trauma	•	Swollen lids	
•	Diplopia	•	Red eyes	

CONDITIONS

Examples of conditions that may require management under the PEC Plan may include, but are not limited to:

•	Ocular hypertension	•	Macular degeneration	
•	Retinal nevus	•	Corneal dystrophy	
•	Glaucoma	•	Corneal abrasion	
•	Cataract	•	Blepharitis	
•	Pink-eye	•	Sty	

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PROCEDURES FOR OBTAINING SUPPLEMENTAL PRIMARY EYECARE SERVICES

COVERED PERSON HAS A GROUP MEDICAL PLAN

The Supplemental Primary EyeCare Plan provides coverage for certain vision-related medical services as a supplement to Covered Person’s group medical plan.  Covered Persons should refer to the plan booklet, certificate of coverage or other benefits description for their group medical plan to determine how to obtain plan benefits.

The provider should first submit a claim to Covered Person’s group medical insurance plan.  Any amounts not paid by the medical plan may then be considered for payment  by VSP.  (This is referred to as “Coordination of Benefits” or “COB." Please refer to the Coordination of Benefits section of Covered Person’s Evidence of Coverage for additional information regarding COB.)

COVERED PERSON DOES NOT HAVE A GROUP MEDICAL PLAN

When Covered Person does not have a group medical plan, the Supplemental Primary EyeCare Plan provides Plan Benefits as follows:

1.  Covered Person contacts VSP Network Doctor and makes an appointment.  

2.  Covered Person pays the applicable Copayment at the time of each Supplemental Primary EyeCare visit and amounts for any additional services not covered by the Plan.

REFERRALS

If Covered Services cannot be provided by Covered Person's VSP Network Doctor, the doctor will refer the Covered Person to another VSP Network Doctor or to a physician whose offices provide the necessary services.

If the Covered Person requires services beyond the scope of the PEC Plan, the VSP Network Doctor will refer the Covered Person back to a physician.

Referrals are intended to insure that Covered Persons receive the appropriate level of care for their presenting condition, Covered Persons do not require a referral from a VSP Network Doctor in order to obtain Plan Benefits.

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PLAN BENEFITS 
VSP NETWORK DOCTORS

COVERED SERVICES

Eye Examinations, Consultations, Urgent/Emergency Care:  Covered in Full after a Copayment of $20.00.
Special Ophthalmological Services:  Covered in Full
Eye and Ocular Adnexa Services:  Covered in Full

EXCLUSIONS AND LIMITATIONS OF BENEFITS

The Supplemental Primary EyeCare Plan provides coverage for limited vision-related medical services as a supplement to Covered Person’s group medical plan.  A current list of the covered procedures will be made available to Covered Persons upon request.

NOT COVERED

•	Services and/or materials not specifically included in this Rider as covered Plan Benefits.
•	Frames, spectacle lenses, contact lenses or any other ophthalmic materials.
•	Orthoptics or vision training and any associated supplemental testing.
•	Surgery, and any pre- or post-operative services, except as an adnexal service included herein.
•	Treatment for any pathological conditions.
•	An eye exam required as a condition of employment.
•	Insulin or any medications or supplies of any type.
•	Local, state and/or federal taxes, except where VSP is required by law to pay.

15	
SUPPLEMENTAL PRIMARY EYECARE PLAN DEFINITIONS

Blepharitis	Inflammation of the eyelids.
	
Cataract	A cloudiness of the lens of the eye obstructing vision.
	
Conjunctiva	The mucous membrane that lines the inner surface of the eyelids and is continued over the forepart of the eye.
	
Conjunctivitis	See Pink Eye.
	
Corneal Abrasion	Irritation of the transparent, outermost layer of the eye.
	
Corneal Dystrophy	A disorder involving nervous and muscular tissue of the transparent, outermost layer of the eye.
	
Diplopia	The observance by a person of seeing double images of an object.
	
Eyecare Professional	Any duly licensed optometrist (O.D.), ophthalmologist or other doctor of medicine (M.D.), or doctor of osteopathy (D.O.).
	
Eye Muscle Dysfunction	A disorder or weakness of the muscles that control the eye movement.
	
Flashes or Floaters	The observance by a person of seeing flashing lights and/or spots.
	
Glaucoma	A disease of the eye marked by increased pressure within the eye which causes damage to the optic disc and gradual loss of vision.
	
Macula	The small, sensitive area of the central retina, which provides vision for fine work and reading.
	
Macular Degeneration	An acquired degenerative disease which affects the central retina.
	
Ocular	Of or pertaining to the eye or the eyesight.
	
Ocular Conditions	Any condition, problem or complaint relating to the eyes or eyesight.
	
Ocular Hypertension	Unusually high blood pressure within the eye.
	
Ocular Trauma	A forceful injury to the eye due to a foreign object.
	
Pink Eye	An acute, highly contagious inflammation of the conjunctiva. Also known as conjunctivitis.
	
Retinal Nevus	A pigmented birthmark on the sensory membrane lining the eye which receives the image formed by the lens.
	
Systemic Condition	Any condition of problem relating to a person’s general health.
	
Sty	An inflamed swelling of the fatty material at the margin of the eyelid.
	
Transient Loss of Vision	Temporary loss of vision.	

16	
PLAN BENEFITS
OPEN ACCESS PROVIDERS

An Eyecare Professional that is an Open Access Provider may require Covered Person to pay for all services in full at the time of the visit.  If so, Covered Person should then submit a claim to VSP for reimbursement.

COVERED SERVICES

Eye Examinations, Consultations, Urgent/Emergency Care: Covered up to $100.00 less a Copayment amount of $20.00.
Special Ophthalmological Services:  Covered up to $120.00 per individual service.
Eye and Ocular Adnexa Services:  Covered up to $120.00 per individual service.

EXCLUSIONS AND LIMITATIONS OF BENEFITS

•	Exclusions and limitations of benefits described above for VSP Network Doctors shall also apply to services rendered by Open Access Providers.
•	Services from a Open Access Provider are in lieu of services from a VSP Network Doctor.
•	There is no guarantee that the amount reimbursed will be sufficient to pay the cost of services or materials in full.
•	VSP is unable to require Open Access Providers to adhere to VSP’s quality standards.

Summary of Benefits and Coverage
SIGNATURE PLAN

Prepared for:  		THERMOCOAX, INC.
Group ID:  		30019805  
Effective Date:		APRIL 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	$20.00 Copay
	Reimbursed up to 
$50.00	Exam covered in full every 12 months**	
	Frames, Lenses or 
Contacts	Glasses: $20.00 Copay (lenses 
and/or frames only);
Up to $60.00 copay for Contact Lens Exam
	Frames reimbursed up to $ 70.00 
SV Lenses reimbursed up to $ 50.00
Bi-Focal Lenses reimbursed up to 
$ 75.00
Tri-Focal Lenses reimbursed up to
$100.00
Lenticular Lenses reimbursed up to
$125.00
ECL reimbursed up to $105.00	Frames covered every 12 months**
Lenses covered every 12 months** 	
	Fees				
** Beginning with the first date of service.
	
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.