Vision Plan Summary

Kalamazoo College, G-1013

Benefit Description – Vision Plan Limits

Benefit Year – January 1 through December 31

Benefit Percentage – Vision Examinations 100%; The Plan will cover one vision examination in a benefit year.

Eyeglass Frames – 100%; The Plan will cover one set of frames, with or without lenses, in any two-benefit-year period.

Eyeglass Lenses, Including Eyeglass Lens Add-Ons Such As Tinting, Ultraviolet Coatings, Scratch-Resistant Coatings, and Anti-Reflective Coatings – 100%

Contact Lenses – 100%

LASIK, PRK, and Other Corrective Vision Surgery – 100%

Maximum Benefit Paid per Covered Person per Benefit Year for All Eligible Vision Services – $300.00

NOTE: If the vision provider will not directly submit a bill for service to the Plan, the covered person typically must pay the purchase price in full and then submit itemized copies of any bills that have been incurred to the claim administrator at the following address: ASR Health Benefits, P.O. Box 6392, Grand Rapids, Michigan, 49516-6392; (616) 957-1751, or (800) 968-2449.

Special Eligibility Provision for Working Spouses and Domestic Partners

A participant’s spouse or domestic partner who is eligible for medical, dental, or vision coverage under his or her own employer’s group health plan will not be eligible to participate in or be covered under this Plan for that benefit type.

The participant is obligated to immediately report to the Plan Administrator any change that would affect his or her spouse’s or domestic partner’s eligibility under this Plan (i.e., the individual changes employers or the individual’s employer offers its employees a medical, dental, or vision plan for the first time). If it is found that a spouse or domestic partner who is eligible for coverage under his or her own employer’s group health plan has not enrolled for his or her own employer’s group health plan as required by this provision, benefits for the spouse or domestic partner may be terminated. Coverage may not be retroactively rescinded except as permitted by law (e.g., in cases of fraud or intentional misrepresentation). Notice that coverage will be retroactively rescinded must be provided 30 days before proceeding with the termination process. Otherwise, coverage will be terminated prospectively once the error is discovered.

The following exceptions to this provision shall apply:

• A participant, spouse, or domestic partner who is an employee of Kalamazoo College and who is married to or in a domestic partner relationship with an individual who is also an employee of Kalamazoo College will not be penalized for declining to enroll separately as individual participants in this Plan.

• A spouse or domestic partner who is required to pay at least 50% or more of the total cost for medical, dental, or vision coverage under his or her employer’s group health plan will not be subject to this provision and can enroll for primary / sole coverage under this Plan for that benefit type.

Special Provision for Injuries Arising Out of Automobile Accidents

In the event that a covered person is injured in an accident involving an automobile, this Plan shall be the primary plan for purposes of paying benefits and the covered person’s automobile insurance shall pay as secondary.

This brochure represents only a summary of your group health benefits Plan as it applies to all eligible employees and dependents. This brochure is not the Plan Document or the Summary Plan Description for ERISA purposes and shall not be relied upon to establish or determine eligibility, benefits, procedures, or the content or validity of any section or provision of the Vision Benefits Plan. Please refer to the Plan Document for specific information regarding Plan provisions. Effective January 1, 2019