WIXLIB

BENEFITS – AFFILIATE PROVIDERSGENERALAffiliate Providers are providers of Covered Services and materials who are not contracted as In-Network Providers but whohave agreed to bill RLHICA’s claims administrator directly for Covered Services provided pursuant to this Schedule.However, some Affiliate Providers may be unable to provide all Covered Services included in this Schedule. CoveredPersons should discuss requested services with their Provider or contact the Member Services Department for details.COPAYMENTThere shall be a Copayment of 10.00 for the examination payable by the Covered Person at the time services arerendered. If materials (lenses, frames or Necessary Contact Lenses) are provided, there shall be an additional 25.00Copayment payable at the time the materials are ordered. The Copayment shall not apply to Elective Contact Lenses.COVERED SERVICES AND MATERIALSEye ExaminationCovered in full *Available once every 12 Months**Comprehensive examination of visual functions and prescription of corrective eyewear.Spectacle LensesSingle Vision, Lined Bifocal or Lined Trifocal Covered in Full*Available once every 12 Months**FramesCovered up to the Plan allowance*Available once every 12 Months**Up to 105.00Available once every 12 Months**CONTACT LENSESElective ContactLenses (MaterialsOnly)The Elective Contact Lens fitting and evaluation services are covered in full once every 12 Months, after a maximum 60.00Copayment.Necessary Contact LensesUp to 210.00*Available once every 12 Months**Necessary Contact Lenses are a Covered Service when specific benefit criteria are satisfied and when prescribed byCovered Person's Provider. Contact Lenses are provided in place of spectacle lens and frame benefits available herein.*Less any applicable Copayment.**Beginning with the first date of service.When contact lenses are obtained, the Covered Person shall not be eligible for lenses and frames again until the next 12months.5VP-164A-2014

LOW VISIONProfessional services for severe visual problems not correctable with regular lenses, including:Supplemental Testing: Up to 125.00†-Includes evaluation, diagnosis and prescription of vision aids where indicated.Supplemental Aids: 75% of Affiliate Provider’s fee up to 1000.00††Maximum benefit for all Low Vision services and materials is 1000.00 every two(2) years and a maximum of two supplemental tests within a two-year periodLow Vision Services are a Covered Service when specific benefit criteria are satisfied and when prescribed by CoveredPerson's Provider.EXCLUSIONS AND LIMITATIONS OF BENEFITS1.Exclusions and limitations of benefits described above for In-Network Providers shall also apply to services renderedby Affiliate Providers.2.Services from an Affiliate Provider are in lieu of services from an In-Network Provider or an Out-of-NetworkProvider.3.RLHICA’s claims administrator is unable to require Affiliate Providers to adhere to its quality standards.4.Where Affiliate Providers are located in membership retail environments, Covered Persons may be required topurchase a membership in such entities as a condition of obtaining Benefits.Eligibility (Certificate Holder and Eligible Dependents) – All dues paying members in good standing are eligible toelect coverage hereunder.Also eligible are your Legal Spouse and any individuals who meet the definition of Child(ren) as set forth in your GroupVision Certificate.Where two individuals are eligible under the same group policy and are legally married to each other, they will beenrolled under one application and will receive Benefits under a single Certificate without coordination of benefits underthe Certificate.You pay the full cost of this coverage.VP-164A-2014-6-

I.Renaissance GroupVision CertificateII.DefinitionsAdditional Benefit RiderRLHICA issues this Renaissance Group VisionCertificate to you, the Certificate Holder. TheCertificate is a summary of your vision benefitscoverage. It reflects and is subject to the agreementbetween RLHICA and your employer or organization(the “Policyholder”).Means a document, attached as a rider to this Certificate(when purchased by the Policyholder) which lists selectedsupplemental vision care services and vision carematerials which a Covered Person is entitled to receiveunder this Certificate.Adverse Benefit DeterminationThe Benefits provided under This Plan may change ifany state or federal laws change.Means any denial, reduction or termination of theBenefits for which you filed a claim or a failure toprovide or to make payment (in whole or in part) of theBenefits you sought, including any such determinationbased on eligibility, or a determination that the item orservice for which Benefits are otherwise provided was notmedically necessary or appropriate based on benefitcriteria.RLHICA agrees to provide Benefits as described inthis Certificate.All the provisions in the following pages, read inconjunction with the Summary of Vision PlanBenefits and all attachments and addendums, form apart of this document as fully as if they were statedover the signature below.Assignments of BenefitsIN WITNESS WHEREOF, this Certificate isexecuted by an authorized officer of RLHICA.Means a written order signed by a Covered Person,eighteen (18) years of age or older, and included witheach claim, directing RLHICA’s claims administrator topay available Benefits to a named Out-of-NetworkProvider.Robert P. MulliganPresident and CEOBenefit AuthorizationMeans a process used to confirm eligibility of anindividual named as a Covered Person and identifyingthose Benefits to which the Covered Person is entitled.Home Office:Benefit YearRENAISSANCE LIFE & HEALTHINSURANCE COMPANY OF AMERICAMeans the calendar year, unless your employer ororganization elects the Policy Year to serve as the BenefitYear. The Benefit Year is specified in the Summary ofVision Plan Benefits Section.Attn: Renaissance AdministrationP.O. Box 30381Lansing, Michigan 48909-7881BenefitsAdministrative Direct Line: 1-800-745-7509Customer Service Direct Line: 1-888-358-9484Means payment for Covered Services.CertificateMeans this document. RLHICA will provide visionBenefits as described in this Certificate. Any changes inthis Certificate will be based on changes to the Policy.Changes to the Certificate may be set forth in theSummary of Vision Plan Benefits Section.7V-200A-2014-SC

Certificate HolderCopaymentMeans you, when your employer or organizationcertifies to RLHICA that you are eligible to receiveBenefits under This Plan.Means the dollar amount you must pay toward visionservices or materials which are not fully covered, andwhich are payable at the time services are rendered ormaterials are ordered.ChildrenCovered PersonMeans your natural children, stepchildren, adoptedchildren, foster children or children by virtue of legalguardianship during the waiting period for legaladoption or guardianship who are or meet one of thefollowing: Your child(ren) who has not yet reached the endof the calendar year of his or her 26th birthday; or, Your child(ren) who: (a) is under the age of 26; (b)is a resident of the same state as the you or is a fulltime student; (c) is dependent upon you or yourLegal Spouse for support; and (d) does not havecoverage, other than coverage as a dependent, underanother vision insurance Plan; or, Your child(ren) or the child(ren) of your LegalSpouse if, pursuant to a court decree you or yourLegal Spouse is financially responsible for thevision care of the child; or Your child(ren) who has reached the end of thecalendar year of his or her 26th birthday and is both(a) incapable of self-sustaining employment byreason of a mental or physical condition and (b)chiefly dependent upon you for support andmaintenance. In the event that RLHICA denies aclaim for the reason that the child has attained theLimiting Age for dependent children, you have theburden of establishing that the child continues tomeet the two criteria specified above. If requestedby RLHICA, you must submit medical reportsconfirming that the child meets the two criteriaspecified above.Means a Certificate Holder or Eligible Dependent (ifdependent coverage is selected), who meets the eligibilitycriteria and on whose behalf premiums have been paid toRLHICA, and who is covered under this Certificate.Covered ServicesMeans the unique vision care services and vision carematerials selected for coverage by your employer ororganization under This Plan. The Summary of VisionPlan Benefits Section lists your Covered Services.Eligible DependentMeans (a) your Legal Spouse; (b) your Child(ren); and(c) any other dependents who meet the criteria foreligibility set forth in the Summary of Vision PlanBenefits Section. If dependent coverage has beenselected, it will be indicated in the Summary of VisionPlan Benefits Section.In-Network ProviderMeans a Provider who has entered into a contract to bepart of the vision care network and to provide CoveredServices to Covered Persons. A current list of InNetwork providers will be made available to CertificateHolders.Legal SpouseMeans a person who is any of the following: (a) yourspouse through a marriage legally recognized by the State inwhich the Policy was issued; (b) your partner through a civilunion legally recognized by the State in which the Policywas issued.Complaints and GrievancesMeans disagreements regarding access to care, qualityof care or treatment and services to be coveredhereunder.Limiting AgeMeans the age at which a Child of yours is no longereligible for Benefits under This Plan pursuant to thedefinition of Child above.Confidential InformationMeans all confidential materials concerning themedical, personal, financial and business affairs ofCovered Persons acquired by RLHICA in the courseof providing the Benefits hereunder.Open Enrollment Period8V-200A-2014-SC

Means the period of time during which an eligibleperson as indicated in the Summary of Vision PlanBenefits Section may enroll or be enrolled to receiveBenefits.III. General EligibilityRulesOut-of-Network ProviderA. You are not eligible for Benefits unless you areeither currently enrolled in This Plan or currentlylisted as an Eligible Dependent.Means a Provider who has not entered into a contractto be part of the vision care network to provideCovered Services to Covered Persons.B. Effective Date of EligibilityPolicy1. Initial Effective Date: All Certificate Holdersand Eligible Dependents on the Effective Date ofthe Policy are immediately eligible for Benefits.Means the insurance contract for the provision ofBenefits to you and your Eligible Dependents betweenRLHICA and your employer or organization. Policyincludes, if applicable, the application, this Certificateand any appendices, supplements, riders, successoragreements or renewals now or hereafter executed.2. After the initial Effective Date:For allCertificate Holders (and their EligibleDependents) not associated with the employer ororganization on the initial Effective Date of thePolicy, eligibility for Benefits will begin, unlessotherwise stated as follows:Policy YearMeans the 12 month period beginning on the EffectiveDate of the Policy and each 12 month renewal periodthereafter.a. Newly hired or rehired employees: Date forwhich employment compensation begins, or,if applicable, that date plus the number ofdays specified as a waiting period in theSummary of Vision Plan Benefits Section;ProviderMeans an optometrist, optician or ophthalmologistlicensed and otherwise qualified to practice visioncare and/or provide vision care materials in the stateor jurisdiction in which vision care services arerendered or vision care materials are provided.b. Spouse: Date of marriage, civil union;c. Newborn: Child's actual date of birth;d. Foster children, legal adoptions orguardianships: Date the Child is placed inthe foster home or with the CertificateHolder; at which time this Child will becovered on the same basis as a natural child;RLHICAMeans Renaissance LifeCompany of America.&HealthInsurancee. Newly adopted child: Coverage begins theearlier of (1) the date the Child is placedwith the Certificate Holder for adoption; (2)the date of an entry of an order grantingcustody of the Child for adoption; or (3) theeffective date of the adoption;Summary of Vision Plan BenefitsMeans a list of the specific provisions of This Planand is a part of this Certificate.This Planf.Means the vision coverage as provided for you andyour Eligible Dependents pursuant to this Certificate.g. All others: Date that RLHICA approves inwriting the enrollment or listing of thosepeople, unless compelled by a court oradministrative order to otherwise provideBenefits for a Child or Eligible Dependent.Urgent ConditionMeans a condition with sudden onset and acutesymptoms which requires the Covered Person toobtain immediate care; or an unforeseen occurrencecalling for immediate action.Once eligible, you and your EligibleDependents must enroll for coverage within30 days from the date upon which you oryour Eligible Dependents become eligible forBenefits under the terms of Section III Bimmediately above. You and your Eligible9V-200A-2014-SCStepchild: Date that the Child’s naturalparent becomes an Eligible Dependent;

Dependents may properly enroll forcoverage by completing all enrollmentforms required by RLHICA andsubmitting such forms to your employeror organization. If you and your EligibleDependents are not properly enrolled forcoverage within 30 days from the dateupon which you and your EligibleDependents become eligible for Benefits,then you and/or your Eligible Dependentsmust wait until the next Open EnrollmentPeriod to enroll.Any Copayments required under this Policy shall bethe personal responsibility of you and your ts are to be paid at the time services arerendered or materials ordered. Amounts whichexceed the Certificate allowances, annual maximumbenefits or any other stated limitations are notconsidered Copayments, but are also theresponsibility of you and your Eligible Dependents.C. Obtaining CoveredProvidersC. Termination of EligibilityfromIn-NetworkTo receive Covered Services from an In-NetworkProvider, You should select an In-Network Provider,schedule an appointment and inform the Provider’soffice that you are a Covered Person under thisCertificate. The In-Network Provider will thenobtain a Benefit Authorization prior to the timeservices are rendered or materials ordered.RLHICA’s claims administrator shall provide aBenefit Authorization to the In-Network Provider.Each Benefit Authorization will contain anexpiration date and must be used by you or yourEligible Dependents to obtain Benefits prior to thedate the Benefit Authorization expires. orizations in accordance with the latesteligibility information furnished by Policyholder andthe past service utilization of you or your EligibleDependents, if any. Any Benefit Authorization soissued shall constitute a certification to the InNetwork Provider that payment will be made to theIn-Network Provider, irrespective of a later loss ofeligibility of you or your Eligible Dependents, aslong as the services are rendered or materialsprovided prior to the Benefit Authorizationexpiration date. If you or your Eligible Dependentsreceive Covered Services from an In-NetworkProvider without a Benefit Authorization, anyservices or materials received from the In-NetworkProvider will be treated as if they were obtained froman Out-of-Network Provider. You or your EligibleDependents may obtain information on ceDental.com, the Member Service’stoll-free number 1-800-877-7195 or by writtenrequest.Eligibility for Benefits will terminate for you andyour Eligible Dependents under This Plan at theearlier of:1. The termination of the Policy; or2. The last day of the month for which paymenthas been made if the employer ororganization fails to make the paymentsrequired by their Policy.Your eligibility, and that of your EligibleDependents, will also terminate if you cease to bea Certificate Holder as defined in the Summary ofVision Plan Benefits Section.An EligibleDependent’s eligibility also terminates upon lackof compliance with the eligibility requirements ofthe Policy.IV. BenefitsCOVERED SERVICESRLHICA agrees to provide Benefits to you and yourEligible Dependents (if dependent coverage isselected) under the policies and procedures ofRLHICA and under the terms and conditions of thisCertificate, including, but not limited to, thecategories of services, exclusions and limitationslisted in the Summary of Vision Plan BenefitsSection.Unless otherwise specified in the Summary ofVision Plan Benefits Section, Covered Services willbe subject to the following terms and conditions:D. Obtaining Covered Services from Out-of-NetworkProvidersA. GeneralThis Certificate provides Benefits for you andyour Eligible Dependents, if dependent coverageis selected by the Policyholder.If required by state law, or if purchased by thePolicyholder, this Policy will provide Benefits forservices and materials received from Out-of-NetworkProviders, based on the Out-of-Network Provider feeschedule. The Out-of-Network Provider may billB. Copayments for Covered Services10V-200A-2014-SCServices

you or your Eligible Dependents for thatProvider’s standard rates, regardless of theamount of this Policy’s Benefits. If you or yourEligible Dependents are eligible for and obtainBenefits from an Out-of-Network Provider, youor your Eligible Dependents remain liable for theOut-of-Network Provider’s full fee. You or yourOut-of-Network Providers may submit requestsfor reimbursement.RLHICA’s claimsadministrator will pay available Benefits to youor your Eligible Dependents, or directly to Outof-Network Providers when claims include avalid Assignment of Benefits. RLHICA maydeny any claims received after one hundred andeighty (180) calendar days from the

V-200A-2014-SC P.O. Box 1596 Indianapolis, IN 46206-1596 888-358-9484 www.RenaissanceVision.com Renaissance South Carolina Group Vision Certificate