DENTAL
VISION We offer two vision plans administered by VSP. Both vision plans pay 100% for an annual eye exam. Both plans include allowances for contact lenses and coverage for retinal imaging. As with dental coverage, you’ll save the most money if you see an in-network VSP provider.
You have two dental plans to choose from, both administered by Delta Dental. You’ll save the most money – you won’t have to file claims yourself – if you see a Delta Dental provider.
Standard Plan
Maximum Plan
Dental Benefits
Standard Plan
Maximum Plan
Vision Benefits
Diagnostic and Preventive Services Oral exams and routine cleaning (two per year), x-rays (one bitewing per year, one full mouth every three years), and fluoride treatments (two per year, to age 19) Basic Services Oral surgery, anesthesia, fillings, extractions, endodontia and periodontia Major Services and Orthodontia* Crowns, cast restorations, fixed bridgework, dentures and orthodontia (to age 19)
Eye Exam One exam per calendar year
Plan pays 100%*
Plan pays 100%*
Plan pays 100%*
Plan pays 100%*
Eyeglass Lenses**
$25 copay
$0 copay
Polycarbonate lenses (children only)
Polycarbonate lenses (adults and children)
Single vision, lined bifocal and lined trifocal lenses
Plan pays 50%
Plan pays 80%
Anti-reflective coating
Standard progressive lenses
All progressive lenses
One pair each calendar year
Plan pays 50%
Plan pays 50%
One pair each calendar year; $210 annual allowance
Frames*
No coverage
Annual Benefit Maximum
$1,500
$2,000
Contact Lenses*
Orthodontia Lifetime Maximum
$1,500
$2,000
Allowance for contact lenses and contact lens exam (fitting and evaluation) 15% savings on exam fees (up to $60 copay) Each calendar year Retinal Imaging Essential Medical Eye Care Additional exams and services beyond routine care to treat immediate issues from pink eye to sudden changes in vision or to monitor ongoing conditions, such as dry eye, diabetic eye disease, glaucoma and more
$150 annual allowance*
$210 annual allowance
Standard Plan
Maximum Plan
Your Weekly Payroll Deduction
Associate Only
$3.65
$5.80
Associate + Spouse Associate + Child(ren)
$8.15
$12.95
$10 copay
$0 copay
$8.95
$14.00
Family
$12.30
$17.15
$20 copay**
$20 copay**
*New enrollees will be subject to a 12-month waiting period for major services and orthodontia.
See Summary Plan Description (SPD) for further details.
Standard Plan
Maximum Plan
Your Weekly Payroll Deduction
Play Offense with Preventive Care Our dental benefits are designed to reward you when you keep up with your preventive care. • Your preventive services are covered at no cost to you when using an in-network provider.
Associate Only
$2.60
$5.30
Associate + Spouse Associate + Child(ren)
$2.90
$6.30
$3.05
$6.45
• If you complete at least one preventive service each plan year, your annual maximum will increase by $200. • Every year following that you complete at least one preventive service, your annual maximum will increase by $200 for up to five years – up to an additional $1,000 in annual maximum benefit. So keep it up! If you miss your preventive service in a year, the annual maximum reverts back to the original benefit and your rollover is lost! Enhanced Benefit for Special Needs Dependents Your dependents with special needs have access to additional visits (up to four total dental cleanings per benefit year) to the dentist’s office and/or consultations that can be helpful prior to the first treatment to help patients learn what to expect and what is needed for a successful dental appointment. Additionally, it covers: • The use of silver diamine fluoride applied to cavities for patients who can’t tolerate the use of dental instruments. • Treatment delivery modifications necessary for dental staff to provide oral health care for patients with sensory sensitivities, behavioral challenges, severe anxiety or other barriers to treatment.
Family
$4.75
$9.85
* You may obtain contacts or eyeglasses every year (but not both in the same year). **See Summary Plan Description (SPD) for further details.
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