Page 10 - 2023 SpecialtyCare Hawaii Benefit Guide

2023 Benefits Guide

Dental Coverage-Delta Dental of Tennessee

SpecialtyCare offers you dental coverage through Delta Dental of Tennessee. It provides cleanings and
preventative care coverage and pays a portion of other services.

To find more information about providers in your area, visit www.deltadentaltn.com. SpecialtyCare participates
in the PPO and Premier Networks.

Dental Plan Name Cleanings &
Plan Provision
In-Network/Out-of-Network Preventive Care
Annual Deductible (Individual/Family) $50/$150 are covered at
Annual Maximum (Per person) $1,250 100%!
Diagnostic and Preventive Care:
Includes cleanings, fluoride treatments, sealants and 100%, no deductible Did you know more than
x-rays 120 disease signs and
Basic Services: Includes fillings, periodontics, scaling 80% after deductible symptoms can be
and root planning, and oral surgery detected through a
routine oral.
Major Services: Includes crowns, bridges, and full 50% after deductible
and partial dentures See your dentist for a
Orthodontia 50% after deductible check-up!
(Children only--up to age 20) $ 1,500-lifetime maximum

Vision Coverage-EyeMed Benefit In-Network Out-Of-Network

Your vision plan is available through Exam $10 copay Up to $35

EyeMed. It provides coverage for Frequency 12 months 12 months
◼ Exam
routine eye exams and pays for all or ◼ Lenses 12 months 12 months
a portion of the cost of glasses or ◼ Frames 24 months 24 months
contact lenses if needed. Frames Up to $140, then 20% Up to $70
discount
More information and a list of Lenses
providers are available at ◼ Single Vision Lenses 100%, after $25 copay Up to $25
www.eyemedvisioncare.com. ◼ Bifocal Lenses 100%, after $25 copay Up to $40
SpecialtyCare uses the Select ◼ Trifocal Lenses 100%, after $25 copay Up to $65
Network. Medically Necessary
Contact Lenses Covered 100% Up to $200
Remember: You can save money by
staying In-Network Elective Contact Lenses in Up to $140 then 15% Up to $112
discount
lieu of glasses

Eye360
Visit a PLUS provider and receive a $0 co-pay vision exam and an additional
$50 frame allowance.

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