10
Hughston Benefits Guide
DENTAL | METLIFE
Premium Plan
Basic Plan
Dental Plan
Annual Deductible Individual | Family Preventive Services
$50 | $150 $50 | $150
100%
100%
Your dental coverage is offered through MetLife for the 2024 plan year. Please review your plan summaries or policy for coverage information and full plan details.
Basic Services Major Services
80% 50% 50%
80% N/A N/A
Orthodontia (Child up to age 26) Annual Benefit Maximum Orthodontia Lifetime Maximum Out-of-Network Reimbursement
$3,000 $1,500
$1,500
N/A
90th UCR Premium Plan
90th UCR
Dental Rates (Bi-Weekly)
Basic Plan
$11.29 $18.90 $20.48 $27.30
$6.82 $11.34 $12.34 $16.27
Employee Employee + Spouse Employee + Child(ren) Family
Out-of-Network Reimbursement
Vision Plan | MetLife
In-Network
Up to $45
Eye Exam Lenses Single Bifocals Trifocals
$10 Copay
$20 Copay $20 Copay $20 Copay
Up to $30 Up to $50 Up to $65
VISION | METLIFE
$130 Allowance after $20 Copay* $130 Allowance $20 Copay
Up to $70
Frames
Contacts Elective Medically Necessary Frequency Exam Lenses or Contacts Frames
Up to $105 Up to $210
Once every 12 months Once every 12 months Once every 24 months
Your vision coverage is offered through MetLife for the 2024 plan year. Please review your plan summaries or policy for coverage information and full plan details.
Vision Rates (Bi-Weekly) Employee Employee + Spouse Employee + Child(ren) Family
$3.41 $5.57 $5.46 $8.98
* Costco, Walmart and Sam’s Club: $70 allowance after $20 eyewear copay.
TELEMEDICINE | TELADOC Telemedicine is an affordable plan that gives you and your family 24/7/365 access to U.S. Board Certified Physicians who can consult, diagnose, and if needed prescribe medication over the phone or via video technology for many common and acute illnesses.
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