Page 6 - ITC Service Group 2022 Benefit Guide

DENTAL & VISION COVERAGE

It’s important to have regular dental exams and cleanings so problems are detected before they become painful — and
expensive. Keeping your teeth and gums clean and healthy will help prevent most tooth decay and is an important part
of maintaining your overall health. We offer two dental plans through Delta Dental.

Enhanced Dental PPO Basic Dental PPO
Plan Provisions
ITC Pays You Pay ITC Pays You Pay
Annual Deductible $50 per person $50 per person
Calendar Year Maximum $2,000 per person $1,000 per person
(Excluding orthodontia)

Preventive Care/Diagnostic 100%* 0% 100%* 0%
Basic and Restorative Services 80% 20% 80% 20%
Major Services 50% 50% Not Covered
Oral Surgery 80% 20% Not Covered

Orthodontia – Up to age 19 50% 50% Not Covered
Orthodontia Lifetime Maximum $1,500 Not Covered
*The deductible does not apply to preventive care/diagnostic services. Sealants are covered at 80% for covered dependent children up to and including age 14 and are
subject to the deductible.
Services received by non-participating providers will be paid at the same rates as participating providers. However, non-participating providers may balance bill you
for charges in excess of Delta Dental’s negotiated rates.

The vision plan provides coverage for routine eye exams and pays for all or a portion of the cost of glasses or contact
lenses. You can choose any provider; however, you always save money if you see in-network providers. We offer vision
coverage through VSP. While you can choose to see any provider, you will always save money when you choose to see
in-network doctors.

VSP Vision Benefits Your Network Cost Non-Network Reimbursement
Exam (Once per plan year) $10 copay Up to $50

Frames (Once every other plan year) $25 copay; Retail $150 allowance Up to $70
Lenses (Once per plan year)
 Single Vision Lenses $0 copay Up to $50
 Bifocal Lenses $0 copay Up to $75
 Trifocal Lenses $0 copay Up to $100

Contact Lenses $0 copay
(Once per plan year in-lieu of glasses) $150 elective allowance Up to $105
Frequency
 Exam Every 12 months Every 12 months
 Lenses Every 12 months Every 12 months
 Frames Every 24 months Every 24 months

Spectacle Options – See web for details
Up to 20% savings on lens extras such as scratch resistant and anti-reflective coatings and progressives
30% off additional prescription glasses and sunglasses when purchased the same day as eye exam from the same VSP provider