Page 6 - ECRM 2022 Benefits Guide (CA)

DENTAL & VISION BENEFITS | keeping you healthy

ECRM offers dental and vision plans that cover routine check-ups
and additional services needed for your health.
Dental Benefits
ECRM’s Dental Plan covers three main types of services:
• Preventive and diagnostic care like routine exams and cleaning, fluoride treatments,
sealants and X-rays
• Basic treatment such as simple fillings and extractions, root canals, oral surgery and gum
disease treatment
• Major treatment such as crowns and dentures
• Orthodontia -Only for dependent children until the end of the month of their 19th birthday

BENEFIT Delta Dental
(IN/OUT OF NETWORK)
Annual Deductible*
Single $50 / $50
Family $150 / $150
Preventive & Diagnostic Care No charge / No charge
Basic Treatment (PDP / R&C)** 20% / 20%
Major Treatment (PDP / R&C)** 50% / 50%
Annual Maximum Benefit (per $1,000 / $1,000
person)
* Annual Deductible applies to Basic and Major services only; ** If you use an out of network provider you must pay any difference between the
dentist’s fee & the plan payment; in network providers accept the plan payment as payment in-full subject to any cost sharing.
Vision Benefits
BENEFIT VSP
(IN/OUT OF NETWORK)
Exams (every 12 months) $10 copay / $50 maximum
Glasses ( every 12 months)
Frames $130 Max / $70 Max
Lenses $30 copay / $50 - $125 Max*
Contacts in lieu of Frames
(every 12 months) $30 Copay / $210Max
Medically Necessary $130 Max / $105 Max
Elective
* Out of Network Max will vary based on lens type (Single, Bifocal, Trifocal, Lenticular)

These charts show how much you pay for certain products and services. Keep in mind, that your Vision and Dental benefit
booklets will provide a comprehensive explanation of all benefit provisions associated with your Vision and Dental plans.