Page 12 - Summit BHC 2022 Benefits Guide
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Dental Vision
Delta Dental of Tennessee VSP
Although you can choose any dental provider, when Our vision care beneits include coverage for eye
you use an in-network dentist, you will generally pay exams, lenses and frames, contact lenses, and
less. If you choose an out-of-network provider, you discounts for laser surgery. When you need services,
may be billed the diference between what Delta consider using an in-network provider for the most
Dental pays, and what your out-of-network provider bang for your buck! When you use an out-of-
charges for the services. network provider, you will be reimbursed for services
up to the allowed amounts below.
UCR Plan MAC Plan
Annual Deductible $50/$150 $50/$150 In-Network Out-of-Network
(individual/family) Examination
Annual Plan Maximum $2,000 $2,000 (every 12 months) $10 copay $45 allowance
Diagnostic and Preventive 100% 100% Materials $25 copay
Services (deductible waived) Lenses (every 12 months)
Basic Services 80% 100% Single $25 copay $30 allowance
Major Services 50% 60% Bifocal $25 copay $50 allowance
Orthodontia (children only 50% 50%
to age 19) Trifocal $25 copay $65 allowance
Lifetime Orthodontia Plan $2,000 $2,000 Frames (every 24 months)
Maximum New Frames $200 allowance $70 allowance
Orthodontia Waiting Period 24 months 24 months Contact Lenses (in lieu of glasses)
Elective $200 allowance $105 allowance
Plan includes out-of-network beneits, see plan summary for additional Medically
details. The UCR plan ofers a richer out-of-network reimbursement than Necessary Covered 100% $210 allowance
the MAC plan.
To locate an in-network provider, please visit To locate an in-network provider, please visit
www.tennessee.deltadental.com. www.vsp.com.
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Delta Dental of Tennessee VSP
Although you can choose any dental provider, when Our vision care beneits include coverage for eye
you use an in-network dentist, you will generally pay exams, lenses and frames, contact lenses, and
less. If you choose an out-of-network provider, you discounts for laser surgery. When you need services,
may be billed the diference between what Delta consider using an in-network provider for the most
Dental pays, and what your out-of-network provider bang for your buck! When you use an out-of-
charges for the services. network provider, you will be reimbursed for services
up to the allowed amounts below.
UCR Plan MAC Plan
Annual Deductible $50/$150 $50/$150 In-Network Out-of-Network
(individual/family) Examination
Annual Plan Maximum $2,000 $2,000 (every 12 months) $10 copay $45 allowance
Diagnostic and Preventive 100% 100% Materials $25 copay
Services (deductible waived) Lenses (every 12 months)
Basic Services 80% 100% Single $25 copay $30 allowance
Major Services 50% 60% Bifocal $25 copay $50 allowance
Orthodontia (children only 50% 50%
to age 19) Trifocal $25 copay $65 allowance
Lifetime Orthodontia Plan $2,000 $2,000 Frames (every 24 months)
Maximum New Frames $200 allowance $70 allowance
Orthodontia Waiting Period 24 months 24 months Contact Lenses (in lieu of glasses)
Elective $200 allowance $105 allowance
Plan includes out-of-network beneits, see plan summary for additional Medically
details. The UCR plan ofers a richer out-of-network reimbursement than Necessary Covered 100% $210 allowance
the MAC plan.
To locate an in-network provider, please visit To locate an in-network provider, please visit
www.tennessee.deltadental.com. www.vsp.com.
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