Page 18 - 2015 First Busey Enrollment Guide
P. 18
Beneits
Enrollment
Vision
Vision
Eye doctors detect problems in vision, overall eye health, and signs of
other health conditions like diabetic eye disease, high blood pressure,
and high cholesterol. We know your eyesight is precious to you, so
we provide vision beneits to make sure your trip to the eye doctor is
reasonably priced.
We partner with Delta Vision/ProTec to offer you comprehensive
vision coverage. Keep in mind, the information in the chart provided is
a summary only. Please refer to your Certiicate of Coverage (COC) for
complete details of plan beneits, limitations, and exclusions on OTL
Visit www.deltadentalil.com.
In-Network Out-of-Network
Vision Exam
Exam Copay $20 copay $35 allowance
Lenses
Single Lens $20 copay $25 allowance
Bifocal Lens $20 copay $40 allowance
Trifocal Lens $20 copay $55 allowance
Frames
Frame Beneit $100 allowance, 20% off $50 allowance
balance over $100
Contact Lenses
Conventional $0 copay, $80 allowance, $64 allowance
15% off balance over $80
Disposable $0 copay, $80 allowance, plus $64 allowance
balance over $80
Visually Required $0 copay, paid-in-full $200 allowance
Frequency
Exams 12 months 12 months
Bi-Weekly Rates Lens 12 months 12 months
Associate Only $2.66 Contacts 12 months 12 months
Associate + Spouse $5.20 (in lieu of glasses)
Associate + Child(ren) $5.82 Frames 24 months 24 months
Family $8.40
18
Enrollment
Vision
Vision
Eye doctors detect problems in vision, overall eye health, and signs of
other health conditions like diabetic eye disease, high blood pressure,
and high cholesterol. We know your eyesight is precious to you, so
we provide vision beneits to make sure your trip to the eye doctor is
reasonably priced.
We partner with Delta Vision/ProTec to offer you comprehensive
vision coverage. Keep in mind, the information in the chart provided is
a summary only. Please refer to your Certiicate of Coverage (COC) for
complete details of plan beneits, limitations, and exclusions on OTL
Visit www.deltadentalil.com.
In-Network Out-of-Network
Vision Exam
Exam Copay $20 copay $35 allowance
Lenses
Single Lens $20 copay $25 allowance
Bifocal Lens $20 copay $40 allowance
Trifocal Lens $20 copay $55 allowance
Frames
Frame Beneit $100 allowance, 20% off $50 allowance
balance over $100
Contact Lenses
Conventional $0 copay, $80 allowance, $64 allowance
15% off balance over $80
Disposable $0 copay, $80 allowance, plus $64 allowance
balance over $80
Visually Required $0 copay, paid-in-full $200 allowance
Frequency
Exams 12 months 12 months
Bi-Weekly Rates Lens 12 months 12 months
Associate Only $2.66 Contacts 12 months 12 months
Associate + Spouse $5.20 (in lieu of glasses)
Associate + Child(ren) $5.82 Frames 24 months 24 months
Family $8.40
18
