Dental and Vision Benefit Plans
|
2011 Delta Dental and Vision (VSP) Benefits Summaries |
EFFECTIVE December 1, 2011 - October 31, 2012
|
Dental Benefits |
In Network |
Out of Network |
|
Vision Benefits |
In Network |
Out of Network |
|
Calendar Year Deductible
Per Person
Family Unit |
$50
$50 |
$150
$150 |
|
Copayment
Exam
Materials |
$10.00
$25.00 |
|
Annual Benefit Maximum
Per Covered Person |
$1,500 |
$1,500 |
|
Eye Exams |
$100% |
$45.00 max |
|
Preventive Service (deductible waived)
Emergency Palliative Treatment
Oral Examination - every 6 months
X-rays - four bitewings every 12 months,
full mouth series every 5 years
Teeth Cleaning - every 6 months
Fluoride Treatment for Children
Space Maintainers for Children
Topical Sealants (up to age 16) |
100% |
100% |
|
Lenses
Frequency: Every 12 months
Single Vision
Bifocal
Trifocal
Lenticular
Note: Percentages and dollar amounts are after copayment. |
100%
100%
100%
100% |
$45.00 max
$65.00 max
$85.00 max
$125.00 max |
|
Basic Service
Laboratory Test
Diagnostic Consultation - one per year
Fillings: Amalgam, Silicate, Acrylic
Crowns: Stainless Steel
Repairs of dentures, bridgework, crowns
Endodontic Services/Root canal
Periodontal Services
Oral Surgery - Uncomplicated extractns
General Anesthesia - Surgical
procedures only
Injectable Antiobiotics |
90% |
80% |
|
Contact Lenses
Fequency: Every 12 Months
Medically Necessary
Elective (maximum)
*Copay does not apply
(If you choose contact lenses,
you will not be eligible to receive lenses for 12 months and frames for 24 months following the date contacts were obtained.) |
$120.00 max
|
$105.00max
|
|
Major Services (six month wait period)
Bridges Installation fixed or removable
Dentures - Full or Partial
Crowns: Acrylic Metal, Porcelain
Inlays
Onlays
Posts |
60% |
50% |
|
Frames
Frequency: Every 24 Months |
$120.00 max
20% off amount over max |
$47.00 max |
|
Orthodontics (Under age 26)
$1,500 Lifetime Maximum
Deductible does not apply |
50% |
50% |
|
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