|
Benefits
Individual Calendar Year Deductible
Family Calendar Year Deductible
|
$50 Basic / Major
$150 Basic / Major
|
|
Co-Insurance
|
| Preventative: |
|
100% of UCR |
| Basic: |
|
80% of UCR |
| Major: |
|
50% of UCR |
Orthodontia:
(Under Age 19) |
|
50% of UCR |
|
|
Maximum Benefit Amount
|
$1,000 per calendar year (Prev/Basic/Maj)
$1,000 lifetime (Orthodontia)
|
|
Waiting Period Before Benefits Payable
|
Major Services: after 12 months of coverage
Orthodontia: after 12 months of coverage
|
|
Benefits
One eye exam, per person,
in a 12 month period
|
$50
|
Frame-type lenses,
per pair in 24 month period
Single vision
Bi-focal
Tri-focal
Lenticular
|
$50
$60
$70
$80
|
Frames, per pair,
in a 24 months period
|
$150
|
Contact lenses, per pair,
in a 24 months period
|
$150
|
This summary is intended to highlight your healthcare benefits and is not a contract of insurance. Please refer to your Summary Plan Description for a complete explanation of covered services, limitations, exclusions and a description of all terms and conditions of coverage. |
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