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