Page 15 - 2022 Mersen Benefit Guide New Hires Final

Dental Plan

The Dental Plan (PDP) is administered by MetLife and offers access to in and out-of-network providers for dental services such as

cleanings, preventive services as well as basic and major services. A comparison of the two plan options is noted below. Always

keep in mind that in-network services/providers will save you money and offer a large network to choose from.

High Option Low Option
Plan Provisions In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
$50/$150 $50/$150
(Individual/Family)
Calendar Year Maximum $2,000 $1,000

Orthodontia Lifetime Maximum $1,500 per individual N/A
Diagnostic and Preventive Services
Covered at 100% Covered at 100%
(e.g., X-rays, cleanings, exams)
Basic and Restorative Services 80%* 80%*
(e.g., fillings)
Major Services
50%* N/A
(e.g., dentures, crowns, bridges)
Orthodontia 50%* for children under age 26 N/A
*After deductible
Orthodontia for dependent children only
Vision Plan

The Vision Care Plan is administered by Highmark Blue Cross Blue Shield Davis Vision and covers a wide range of vision-

related services and products; network of access points, including both private practice and leading retail chain providers.

Highmark BCBS Davis Vision Plan
Plan Provision In-Network Out-of-Network

Covered 100%
Exam Up to $30 off
(There is a hardware copay of $10)
Frames
$120 allowance Up to $30
Fashion/Premier level frames
100%/$25 copay N/A
from “The Collection”
Lenses
 Single vision lenses Up to $25 off
 Bifocal lenses Covered 100% Up to $35 off
 Trifocal lenses Up to $45 off
Contact Lenses
 Elective Covered 100% Up to $225 off
 Medically necessary N/A
Frequency
 Exam 12 Months 12 Months
 Lenses 12 Months 12 Months
 Frames 12 Months 12 Months
For more information, please review your benefit summary.

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PLEASE NOTE: Employees covered by a collective bargaining agreement should refer to their union agreement to determine if they are eligible for these plans.