Dental benefits administered by Delta Dental Regular dental visits certainly play a role in helping you and your family Live Well. Good dental care helps prevent or treat periodontal disease – a primary cause of tooth loss in people of all ages, according to the U.S. Department of Health and Human Services. We offer two dental plans administered by Delta Dental : the Standard Plan and the Maximum Plan. The plans differ in the type of care covered and what you pay for services. You may see any dentist, but when you use a Delta Dental provider, you’ll save money and you won’t have to file any claims. Both plans cover two complete exams annually. DENTAL
Vision benefits administered by VSP Like any other health factor, your vision requires regular care. Our vision plan helps you and your family Live Well by keeping you seeing clearly. We offer two vision plans administered by VSP : the Standard Plan and the Maximum Plan. The plans differ in the type of care covered and what you pay for services. You may see any provider, but when you use a VSP network provider, you’ll save money and you won’t have to file any claims. Both vision plans pay 100% for an annual eye exam. The Standard Plan provides additional benefits for eyeglass lenses and contact lenses. The Maximum Plan also provides benefits for frames. You can get frames once every calendar year on the Maximum Plan, and standard progressive lenses are covered in full on the Standard Plan. Both plans include allowances for contact lenses and full coverage for retinal imaging after a $10 copay. VISION
DENTAL BENEFITS*
STANDARD PLAN MAXIMUM PLAN
VISION BENEFITS*
STANDARD PLAN
MAXIMUM PLAN
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)
Plan pays 100%*
Plan pays 100%*
EYE EXAM (One exam each calendar year)
Plan pays 100%*
Plan pays 100%*
EYEGLASS LENSES* • Single vision, lined bifocal, lined trifocal lenses • Anti-reflective coating • One pair each calendar year
• $25 copay • Polycarbonate lenses (children only) • Standard progressive lenses
• $15 copay • Polycarbonate lenses (adults and children) • All progressive lenses One pair each calendar year; annual allowance of $180**
Plan pays 50%
Plan pays 80%
FRAMES
No coverage
Plan pays 50%
Plan pays 50%
CONTACT LENSES** • Allowance for contact lenses and contact lens exam (fitting and evaluation) • 15% savings on exam fees (up to $60 copay) • Each calendar year
$150 annual allowance**
$180 annual allowance**
ANNUAL BENEFIT MAXIMUM
$1,500
$2,000
ORTHODONTIA LIFETIME MAXIMUM
$1,500
$2,000
YOUR WEEKLY PAYROLL DEDUCTION
STANDARD PLAN MAXIMUM PLAN
RETINAL IMAGING
$10 copay
$10 copay
ASSOCIATE COVERAGE
$3.45
$5.50
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
ASSOCIATE + SPOUSE COVERAGE
$7.65
$12.40
$20 copay*
$20 copay*
ASSOCIATE + CHILD(REN) COVERAGE
$8.45
$13.20
ASSOCIATE + FAMILY COVERAGE
$11.60
$16.15
YOUR WEEKLY PAYROLL DEDUCTION
STANDARD PLAN
MAXIMUM PLAN
Weekly premiums are deducted pre-tax , saving you even more money. *See Summary Plan Description (SPD) for further details. **New enrollees will be subject to a 12-month waiting period for major services and orthodontia.
ASSOCIATE COVERAGE
$3.00 $3.35 $3.55 $5.10
$4.70 $7.30 $7.50
ASSOCIATE + SPOUSE COVERAGE ASSOCIATE + CHILD(REN) COVERAGE ASSOCIATE + FAMILY COVERAGE
$10.10
Weekly premiums are deducted pre-tax , saving you even more money. *See Summary Plan Description (SPD) for further details. **You may obtain contacts or eyeglasses every year (but not both in the same year).
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