Page 12 - Acadia 2022 Benefits Guide | DBI
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Discover My Acadia Health
Dental Plans Vision Plan
Acadia offers you and your eligible dependents the opportunity Acadia offers you and your eligible dependents vision coverage
to enroll in dental coverage through Delta Dental of Tennessee. through NVA. To ind a NVA doctor or retail provider, visit
You have the option to enroll in either the Delta Dental of TN www.e-nva.com or call 800.672.7723. You will receive an ID card
Value Plan or the Base Plan. As a member of the: from NVA.
y Value Plan—you have access to only the Delta Dental PPO
network BENEFIT PLAN IN-NETWORK OUT-OF-
NETWORK
y Base Plan—you have access to both the Delta Dental PPO
and Delta Dental Premier networks Exam $0 copay Up to $50
(every 12 months)
You may be balance billed for seeing a non-network dentist, Lenses
which means that you will be responsible for the difference. (every 12 months)
y Single Vision $10 copay Up to $50
VALUE PLAN BASE PLAN y Lined Bifocal $10 copay Up to $60
PROVISION PPO NETWORK PREMIER/PPO y Lined Trifocal $10 copay Up to $70
ONLY NETWORK y Lenticular $10 copay Up to $100
Annual Deductible Progressive Lenses
(Individual/Family) $50/$150 $50/$150 (every 12 months)
y Tier 1 $10 copay NA
Is the Deductible Waived Yes Yes y Tier 2 (Standard) $80 + $10 copay NA
Tier 3–4 (Premium)
y
for Preventative Services? See plan document for $100-$120 NA
Annual Maximum additional lens options + $10 copay
(per person for all $500 $1,500 and discounts
services including
preventative care) Frames $170 allowance Up to $100
then 20% off
Diagnostic and (every 12 months) balance
Preventive: Includes Plan pays Plan pays
cleanings, luoride 100% 100% Contact Lenses $145 allowance Up to $105
Up to $50
treatments, and x-rays (every 12 months— for contacts; $50 contact lens it/
contact lens it/
Basic Services: Includes instead of glasses) follow-up copay follow-up
illings, sealants, 20%*
periodontics, scaling and 20%* Extra Savings Available
root planing, and oral No (endo/ and Discounts through NVA Not available
surgery perio/surgery) sunglasses and laser Doctors Only
vision correction
Major Services: Includes
crowns, bridges and full No coverage 50%*
and partial dentures Note: Diabetic Eyecare Plus Program included in-network
copay of $20 with services related to diabetic eye disease,
Orthodontia: Children 50%* glaucoma and age-related macular degeneration.
Only (to end month of No coverage $1,500 lifetime
age 19) maximum
Note: Table relects employee portion of cost in-network.
Please note that if your provider is out of network, you may be
responsible for the amount that is over the Reasonable and
Customary.
* After you meet the deductible
12 | Detroit Behavioral Institute (DBI)
Dental Plans Vision Plan
Acadia offers you and your eligible dependents the opportunity Acadia offers you and your eligible dependents vision coverage
to enroll in dental coverage through Delta Dental of Tennessee. through NVA. To ind a NVA doctor or retail provider, visit
You have the option to enroll in either the Delta Dental of TN www.e-nva.com or call 800.672.7723. You will receive an ID card
Value Plan or the Base Plan. As a member of the: from NVA.
y Value Plan—you have access to only the Delta Dental PPO
network BENEFIT PLAN IN-NETWORK OUT-OF-
NETWORK
y Base Plan—you have access to both the Delta Dental PPO
and Delta Dental Premier networks Exam $0 copay Up to $50
(every 12 months)
You may be balance billed for seeing a non-network dentist, Lenses
which means that you will be responsible for the difference. (every 12 months)
y Single Vision $10 copay Up to $50
VALUE PLAN BASE PLAN y Lined Bifocal $10 copay Up to $60
PROVISION PPO NETWORK PREMIER/PPO y Lined Trifocal $10 copay Up to $70
ONLY NETWORK y Lenticular $10 copay Up to $100
Annual Deductible Progressive Lenses
(Individual/Family) $50/$150 $50/$150 (every 12 months)
y Tier 1 $10 copay NA
Is the Deductible Waived Yes Yes y Tier 2 (Standard) $80 + $10 copay NA
Tier 3–4 (Premium)
y
for Preventative Services? See plan document for $100-$120 NA
Annual Maximum additional lens options + $10 copay
(per person for all $500 $1,500 and discounts
services including
preventative care) Frames $170 allowance Up to $100
then 20% off
Diagnostic and (every 12 months) balance
Preventive: Includes Plan pays Plan pays
cleanings, luoride 100% 100% Contact Lenses $145 allowance Up to $105
Up to $50
treatments, and x-rays (every 12 months— for contacts; $50 contact lens it/
contact lens it/
Basic Services: Includes instead of glasses) follow-up copay follow-up
illings, sealants, 20%*
periodontics, scaling and 20%* Extra Savings Available
root planing, and oral No (endo/ and Discounts through NVA Not available
surgery perio/surgery) sunglasses and laser Doctors Only
vision correction
Major Services: Includes
crowns, bridges and full No coverage 50%*
and partial dentures Note: Diabetic Eyecare Plus Program included in-network
copay of $20 with services related to diabetic eye disease,
Orthodontia: Children 50%* glaucoma and age-related macular degeneration.
Only (to end month of No coverage $1,500 lifetime
age 19) maximum
Note: Table relects employee portion of cost in-network.
Please note that if your provider is out of network, you may be
responsible for the amount that is over the Reasonable and
Customary.
* After you meet the deductible
12 | Detroit Behavioral Institute (DBI)
