Page 9 - ProModel 2015 Benefits Guide
P. 9
Dental Plan Summary
The dental insurance coverage is administered by Capital BlueCross.
Highlights of the plan are provided below.
Beneits In-Network Non-Network
Calendar Year Deductible NA NA DENTAL AND
Calendar Year Maximum $1,000 per person $1,000 per person
Class 1—Preventive 100% 100% VISION
Class 2—Basic 100% 100%
Class 3—Major 50% 50%
Class 4—Orthodontic 50% 50%
Lifetime Orthodontic Maximum
(dependents to age 19 only) $1,500 $1,500
This is a PPO plan with in-network and out-of-network coverage. The
only difference between in-network and out-of-network services is
that when you visit a participating dental provider, the provider must How Do I Find a
accept the insurance company’s payment, as payment in full, minus Participating Dental or
your deductible and coinsurance. If you visit an out-of-network dental Vision Provider?
1. Go to www.capbluecross.com
or vision provider, the provider can bill you for any amount over the and click on “Find a doctor of
contract allowances, plus your deductible and coinsurance. You may facility”
experience higher out-of-pocket expenses when visiting an out-of- 2. Click to search by Provider type
network dentist. Please be aware the out-of-network provider can also or specialty
bill you at the time of service, in which case you would then have to 3. Select General Practice Dentistry,
ile a manual paper claim with the insurance company to receive your Orthodontics, Oral Surgery,
reimbursement. Ophthamology, or Optometrist,
etc.
4. For plan select “PPO Capital Blue
Vision Plan Summary Cross and Federal Marketplace
The vision insurance coverage is administered by Capital BlueCross. Plans”
Highlights of the plan are provided below.
Beneit Reimbursement
Examination (Adults 19 and over; once every 24 months 100% of Reasonable and
Children under 19; one every 12 months) Customary
Lenses (Adults 19 and over; once every 24 months 100% of Reasonable and
Children under 19; one every 12 months) Customary
Single Vision Up to $24
Bifocal Up to $36
Trifocal Up to $46
Aphakic Up to $72
Contacts Up to $48
Frames Once every 24 months Maximum of $24,
regardless of age
9
The dental insurance coverage is administered by Capital BlueCross.
Highlights of the plan are provided below.
Beneits In-Network Non-Network
Calendar Year Deductible NA NA DENTAL AND
Calendar Year Maximum $1,000 per person $1,000 per person
Class 1—Preventive 100% 100% VISION
Class 2—Basic 100% 100%
Class 3—Major 50% 50%
Class 4—Orthodontic 50% 50%
Lifetime Orthodontic Maximum
(dependents to age 19 only) $1,500 $1,500
This is a PPO plan with in-network and out-of-network coverage. The
only difference between in-network and out-of-network services is
that when you visit a participating dental provider, the provider must How Do I Find a
accept the insurance company’s payment, as payment in full, minus Participating Dental or
your deductible and coinsurance. If you visit an out-of-network dental Vision Provider?
1. Go to www.capbluecross.com
or vision provider, the provider can bill you for any amount over the and click on “Find a doctor of
contract allowances, plus your deductible and coinsurance. You may facility”
experience higher out-of-pocket expenses when visiting an out-of- 2. Click to search by Provider type
network dentist. Please be aware the out-of-network provider can also or specialty
bill you at the time of service, in which case you would then have to 3. Select General Practice Dentistry,
ile a manual paper claim with the insurance company to receive your Orthodontics, Oral Surgery,
reimbursement. Ophthamology, or Optometrist,
etc.
4. For plan select “PPO Capital Blue
Vision Plan Summary Cross and Federal Marketplace
The vision insurance coverage is administered by Capital BlueCross. Plans”
Highlights of the plan are provided below.
Beneit Reimbursement
Examination (Adults 19 and over; once every 24 months 100% of Reasonable and
Children under 19; one every 12 months) Customary
Lenses (Adults 19 and over; once every 24 months 100% of Reasonable and
Children under 19; one every 12 months) Customary
Single Vision Up to $24
Bifocal Up to $36
Trifocal Up to $46
Aphakic Up to $72
Contacts Up to $48
Frames Once every 24 months Maximum of $24,
regardless of age
9
