Page 5 - FantaSea 2021 Benefits Guide

Dental Coverage

Regular dental exams
can help you and your Plan Provision Delta Dental PPO
dentist detect problems In-Network Out-of-Network
in the early stages when
treatment is simpler and Annual Deductible (Individual/Family) $50/$150
costs are lower. Keeping
your teeth and gums Annual Maximum (Per person) $1,000
clean and healthy will Diagnostic and Preventive Care: 100% of
help prevent most tooth Includes cleanings, fluoride treatments, 100%, no ded customary
sealants and x-rays
allowance
decay and periodontal 60% after ded
disease, and it is an Basic Services: Includes fillings, periodontics, 80% after ded of customary
scaling and root planning, and oral surgery
important part of allowance
maintaining your medical Major Services: Includes crowns, bridges and 50% after ded
health. The Delta Dental full and partial dentures 50% after ded of customary
allowance
plan provides Not Covered
comprehensive coverage. Orthodontia Services
Dependent Children are
covered until age 26.

Vision Coverage Benefit In-Network

The Horizon vision plan
covers routine eye exams Exam $10 copay
and also pays for all or a Lenses $25 copay
portion of the cost of Frequency
glasses or contact lenses Exam Once per calendar year
Once per calendar years
if you need them. Lenses Once per two calendar years
Members will utilize the Frames

Davis Vision network of Frames & Contact
physicians. Allowance $130
Dependent Children are
covered until age 26. Single Vision Lenses Included
Bifocal Lenses Included
Trifocal Lenses Included

Elective Contact Lenses in Up to $130
lieu of glasses Plus a 15% discount on any overage

FANTASEA RESORTS