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UniView Vision ComponentBenefit Program‐ Fully Insured(Component Document 2)Plan AdministratorTim KlopfensteinVirginia Private Colleges Benefits Consortium, Inc.118 East Main StreetP.O. Box 1005Bedford, VA 24523(540) 586‐1803Named FiduciaryUNICARE Life & Health Insurance Company233 S. Wacker Drive, Suite 3700Chicago, IL 60606Claims AdministratorUniView Vision233 S. Wacker Drive, Suite 3700Chicago, IL 60606(314) 923‐7655Funding Medium and Type ofPlan AdministrationThe UniView Vision Component Benefit Program is fully insuredunder a contract between the Consortium and UNICARE Life &Health Insurance Company. UNICARE Life & Health InsuranceCompany is responsible for administering the UniView vision planand for making claim payments. UNICARE Life & Health InsuranceCompany is responsible to fund the claim payments.Plan contributions are paid in whole or in part by the Employersout of their general assets and in whole or in part by Employees’pre‐tax payroll deductions. The Plan Administrator will provide aschedule of the applicable premiums during the initial andsubsequent open enrollment periods and upon request, asapplicable.Dental Component BenefitProgram‐ Self‐Funded(Component Document 3)Plan AdministratorVersion 01/2019Tim KlopfensteinVirginia Private Colleges Benefits Consortium, Inc.118 East Main StreetP.O. Box 1005Bedford, VA 24523(540) 586‐18035

Named FiduciaryThe Board of Directors of the Virginia Private Colleges BenefitsConsortium, Inc.Claims AdministratorDelta Dental of Virginia4818 Starkey RoadRoanoke, VA 24018(800) 237‐6060Funding Medium and Type ofPlan AdministrationThe Dental Component Benefit Programs are self‐funded underapplicable contracts between the Consortium and Delta Dental.Delta Dental is responsible for paying claims and administering thedental plan program options. The Consortium is responsible tofund the claim payments.Plan contributions are paid in whole or in part by the Employersout of their general assets and in whole or in part by Employees’pre‐tax payroll deductions. The Plan Administrator will provide aschedule of the applicable premiums during the initial andsubsequent open enrollment periods and upon request, asapplicable.Version 01/20196

Section 3Eligibility and Participation RequirementsThe eligibility and participation requirements for the Component Benefit Programs are set forth below.The following individuals are eligible for coverage in the Component Benefit Programs:PERSONEmployeeDEFINITIONSee Glossary DefinitionWHEN ELIGIBLEThe Employee meets the requirements for eligibility andproperly enrolls in the Plan; andMakes any required Contributions toward the cost ofcoverage for the Participant and any Covered Dependent(s).The formula used for allocating the required Contributionsbetween the Member and its Employees must be approvedby the Board of Directors. The amount of the respectiveContributions shall be set forth in notices from the PlanAdministrator and may be changed from time to time by theBoard of Directors.Part TimeEmployeeSee Glossary DefinitionA Part Time Employee must properly enroll in the Plan,continuously meet the requirements for eligibility and paythe required contributions on a timely basis, as described inthis Section on Eligibility and Enrollment.EligibleRetireeSee Glossary DefinitionIf a Participant becomes an Eligible Retiree, such Participantmay continue as a Covered Person subject to any limitationscontained herein;An Eligible Retiree may continue as a Covered Person untilthe date the Eligible Retiree becomes eligible for Medicare;If an Eligible Retiree or an Eligible Retiree’s Dependentspouse who was a Covered Person terminates participationin the Plan, such person may not become a Covered Personthereafter.SpouseSee Glossary Definitionof “Dependent”A Spouse will be considered an eligible Dependent from thedate of marriage, provided the Spouse is properly enrolled asa Dependent within 31 days of the date of marriage.DependentChildrenSee Glossary Definitionof “Dependent”Initial Enrollment. If the Dependent satisfies the definitionof a “Dependent” in the Glossary, and if a Participantproperly enrolls the Dependent within 31 days of the date ofhire, the Dependent’s Effective Date shall be the same day asthe Participant’s Effective Date. A Disabled Child must meetthe definition of a Disabled Child and satisfy therequirements for Initial Enrollment of a Disabled Child, bothcontained in the Glossary.Later‐Acquired Dependent. If a Participant, after initialenrollment, acquires a new eligible Dependent, theParticipant may complete, sign and return an application toVersion 01/20197

PERSONDependentChildrenSpouse andDependentsof EligibleRetireeDEFINITIONWHEN ELIGIBLEthe Plan Administrator within the period set forth in theSpecial Enrollee section. If the newly acquired Dependent(s)are enrolled within this period, the effective date of thatDependent’s coverage is the first date in which theDependent met the definition of Dependent.If an Eligible Retiree’s Dependent is not a Covered Person onthe day prior to the time the Participant becomes an EligibleRetiree, such Dependent may not thereafter become aCovered Person in the Plan unless the Dependent is a SpecialEnrollee;A Dependent spouse acquired by marriage or domesticpartnership (where the Member has executed a Rideraffording domestic partner coverage) after a Participantbecomes an Eligible Retiree may not be a Special Enrollee;If an Eligible Retiree or an Eligible Retiree’s Dependentspouse who was a Covered Person terminates participationin the Plan, such person may not become a Covered Personthereafter;Upon an Eligible Retiree’s death or termination ofparticipation due to eligibility for Medicare, any CoveredSpouse and Covered Dependent may remain a CoveredDependent until the earlier of the date of such CoveredSpouse’s death or termination of participation due toMedicare eligibility. An Eligible Retiree’s Dependent who iseligible for Medicare may not be a Covered Person in thePlan. If the Covered Spouse terminates participation due todeath or eligibility for Medicare, or if no spouse is covered atthe time of the Eligible Retiree’s termination of participation,any Covered Dependent may remain a Dependent for theapplicable period of Continuation of Coverage as set forthunder COBRA.Upon the death or retirement of a Participant who isMedicare eligible and who, except for such eligibility forMedicare, would qualify as an Eligible Retiree, any CoveredDependents may remain a Covered Dependent on the samebasis as the Covered Dependents of an Early Retiree who isterminating due to death or eligibility for Medicare; andIf an Eligible Retiree terminates participation in the Plan forany reason other than for death or eligibility for Medicare,the Covered Dependents of such Eligible Retiree shallterminate participation in the Plan as of the Eligible Retiree’stermination of participation.Version 01/20198

PERSONSpecial EnrolleeDEFINITIONLater‐Acquired Dependent. If a Participant, after initialenrollment, acquires a new eligible Dependent, theParticipant may complete, sign and return anapplication to the Plan Administrator within the periodset forth below. If the newly acquired Dependent(s)are enrolled within this period, the effective date ofthat Dependent’s coverage is the first date in which theDependent met the definition of Dependent.Spouse Upon Marriage. A spouse will be consideredan eligible Dependent from the date of marriage,provided the spouse is properly enrolled as aDependent within 31 days of the date of marriage.Newborn or Adopted Children. Newborn and newlyadopted children shall be covered for Injury or Illnessfrom the moment of birth, adoption, or placement foradoption. Covered Expenses include the necessarycare or treatment of medically diagnosed CongenitalDefects, birth abnormalities or prematurity, providedthe child is properly enrolled as a Dependent within 60days of the child’s date of birth, adoption or placementfor adoption. This provision shall not apply to or in anyway affect the maternity coverage applicable to themother.Siblings and Other Dependents Upon Birth orAdoption. If a Participant’s other Dependents are notCovered Persons, the Participant may enroll theseother Dependents along with a newborn or adoptedchild as described in the subsection above. If theParticipant enrolls the other Dependents within 60days, the Special Enrollment Date and coverage shallbecome effective on the child’s date of birth, adoption,or upon placement for adoption.Loss of Alternate Health Coverage. A Participant or aDependent who was previously eligible for coverage,but did not enroll because of alternate healthcoverage, may complete, sign and return an applicationto the Plan Administrator within the 31 day SpecialEnrollment Period following the Participant orDependent’s loss of such other coverage (includingcoverage through the Marketplace) due to any of thefollowing:Exhaustion of COBRA Continuation Coverage;Version 01/20199WHEN ELIGIBLEInitial Enrollment. If aParticipant enrolls aDependent within 31days of the date of hire,the Dependent’sEffective Date shall bethe same day as theParticipant’s EffectiveDate.

PERSONSpecial EnrolleeDEFINITIONLoss of eligibility for such other coverage due todivorce, legal separation, death, termination ofemployment or reduction of hours of employment;Termination of Employer contributions; orReaching the lifetime limit on all benefits under theEligible Employee’s or Dependent’s prior plan.For a Disabled Child only, a significant cost increase ofthe Disabled Child’s coverage through the Marketplacewill constitute a loss of coverage and thus a specialenrollment right for the Disabled Child, provided thatthe child meets the definition of a Disabled Child andsatisfies the requirements for Special Enrollment of aDisabled Child, both contained in the Glossary.Individuals who lose coverage due to nonpayment ofpremiums or for cause (e.g. filing fraudulent claims)shall not be Special Enrollees hereunder. Coverage fora Special Enrollee hereunder shall begin as of the dayfollowing loss of alternate health coverage, but notmore than 31 days prior to the date the enrollmentapplication is received by the Plan Administrator.Employees and Dependents who are eligible but notenrolled for coverage when initially eligible maybecome a Special Enrollee in two additionalcircumstances:o The Employee’s or Dependent’s Medicaid or CHIPcoverage is terminated as a result of loss of eligibilityand the Employee requests coverage under the Planwithin 60 days after the termination; oro The Employee or Dependent become eligible for apremium assistance subsidy under Medicaid or CHIP,and the Employee requests coverage under the Planwithin 60 days after eligibility is determined.Court Order or Decree. If a Dependent is acquiredthrough a court order, decree, or marriage, thatDependent will be considered a Dependent from thedate of such court order, decree, or marriage, providedthat this new Dependent is properly enrolled within 31days of the court order, decree, or marriage.Version 01/201910WHEN ELIGIBLE

PERSONSpecial Enrollee3.1DEFINITIONQualified Medical Child Support Order. A child maybecome eligible for coverage as set forth in a QualifiedMedical Child Support Order (QMCSO). The PlanAdministrator will establish written procedures fordetermining (and have sole discretion to determine)whether a medical child support order is qualified andfor administering the provisions of benefits under thePlan pursuant to a QMCSO. The Plan Administratormay seek clarification and modification of the order, upto and including the right to seek a hearing before thecourt or agency which issued the order.WHEN ELIGIBLEChange in StatusThe Plan allows election changes outside of Open Enrollment based on certain change in status events.The cafeteria plan of the Member governs whether a corresponding mid‐year change is allowed to aParticipant’s pre‐tax salary reduction election. Participants should refer to the Member’s Plandocument governing the cafeteria plan to determine whether pre‐tax salary reduction elections can bechanged for the following change in status events allowed under this Plan: When a change in contribution is significant, a Participant may either increase thecontributions or change to a less costly coverage election. When a new benefit option is added, a Participant may change to elect the newbenefit option. When a significant overall reduction is made to a benefit option, a Participant mayelect another available benefit option. A Participant may make a coverage election change if the spouse or Dependent iscovered as an Employee or Dependent under another employer plan and that planincurs a change such as adding or deleting a benefit option; ando Allows a permitted mid‐year election change; oro3.2Allows election changes due to that Plan’s annual Open Enrollment, whichdoes not coincide with this Plan’s annual Open Enrollment.Participant’s and Dependent’s Termination of ParticipationA Participant and Dependent’s participation under the Plan shall terminate on the earlier of thefollowing occurrences: The end of the month in which the Participant Terminates Employmen

Anthem Blue Cross and Blue Shield 2015 Staples Mill Road Richmond, VA 23230 The Anthem Vision Component Benefit Program is fully insured under a contract between the Consortium and Anthem. Anthem is responsible for administering the Anthem vision plan and for making claim payments.