Page 11 - Monster Energy 2021-2022 Benefits Guide
P. 11
dental and vision
DENTAL Your dental health is tied to your overall health, so be sure to have regular dental exams and cleanings.
Choose from two Cigna dental plans.
DENTAL BENEFIT CIGNA DHMO* CIGNA PPO
In-Network Coverage Only In-Network Out-of-Network
Annual Deductible None $50/member; $150/family
Calendar Year Benefits Maximum Unlimited $2,000 per individual
Oral Exams Plan pays 100% Plan pays 100%
Routine Cleanings Plan pays 100% Plan pays 100%
X-rays Plan pays 100% Plan pays 100%
Fillings Plan pays 100% 10% after deductible 20% after deductible
Routine Extractions $12 Copay, then 10% after deductible 10% after deductible 20% after deductible
Porcelain Crowns $410 - $500 Copay 40% after deductible 50% after deductible
$2,040 children; $2,376 adults
Orthodontia Lifetime Maximum Child/Adult Plan pays 50% up to $2,000
other costs may apply
YOUR BI-WEEKLY COST
Employee Only $0.00 (100% company paid) $0.00 (100% company paid)
Employee + Spouse $4.27 $12.69
Employee + Child(ren) $4.96 $14.54
Employee + Family $7.15 $21.69
* CIGNA Dental HMO is not available in the following states: Alaska, Hawaii, Idaho, Maine, Montana, New Mexico, North Dakota, South Dakota, Vermont
and Wyoming
vision The EyeMed vision plan provides coverage for routine eye exams, glasses and contact lenses.
VISION BENEFIT EYEMED VISION PLAN
In-Network Coverage Out-of-Network Allowance
Exams – every 12 months) $0 Plan pays up to $35
Plan pays up to $35 (Single)
Lenses – every 12 months $20, then Plan pays 100% Plan pays up to $49 (Bifocal)
Plan pays up to $74 (Trifocal)
Plan pays up to $200,
Frames – every 12 months Plan pays up to $100
then 20% of any amount over $200
Plan pays up to $200, Plan pays up to $120
Contacts – every 12 months
then 15% of any amount over $200 (up to $160 for disposable contact lenses)
YOUR BI-WEEKLY COST
Employee Only $0.00 (100% company paid)
Employee + Spouse $1.38
Employee + Child(ren) $1.62
Employee + Family $2.31 / 11
