Accident and Health Product Filing

Stand-Alone Vision Model Language

  • The following is model language for all individual, small group and large group stand-alone vision coverage.
  • The documents available in this table are in Word format.
Subject Model Language Date

Cover Page

05/31/2022

Individual - Table of Contents

05/31/2022

Group - Table of Contents

05/31/2022

Definitions

05/31/2022

How Your Coverage Works (Introduction, Selecting a Primary Care Dentist, Preauthorization, Medically Necessary)

05/31/2022

Access to Care and Transitional Care (Referrals, Specialty Care Provider as a PCD)

05/31/2022

Cost-Sharing Expenses and Allowed Amount

05/31/2022

Individual - Who Is Covered (Eligibility)

05/31/2022

Group - Who Is Covered (Eligibility)

05/31/2022

Routine Vision Care

05/31/2022

Exclusions

05/31/2022

Claim Determinations

05/31/2022

Grievance

05/31/2022

Utilization Review

05/31/2022

External Appeal

05/31/2022

Coordination of Benefits (Group Only)

05/31/2022

Termination

05/31/2022

Extension of Benefits

05/31/2022

Continuation (Group Only)

05/31/2022

Temporary Suspension Rights for Members of the Armed Forces (Individual Only)

05/31/2022

General Provisions (Incontestability, Legal Actions, Subrogation, Unilateral Modification)

05/31/2022

Schedule of Benefits

05/31/2022

Domestic Partner Rider (Group Only)

05/31/2022