Page 5 - VSolvit 2021 Benefits Brochure
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VSolvit
2021 Employee Benefits Brochure
Dental Plans ‐ Cigna
DHMO* DPPO
In‐Network In‐Network**
Annual Benefit Maximum Unlimited $5,000
Calendar Year Deductible:
Individual / Family None $50 / $150
Preventive & Diagnostic:
Office Exams / Cleanings / X‐Rays See fee schedule Covered 100%***
Basic Services: See fee schedule
Fillings / Root Canal / Oral Surgery 80%
Major Services: See fee schedule
Crowns / Dentures / Bridges 50%
$1,608 child
Orthodontia $1,800 adult 50% up to $1,500 lifetime
max (child only) ***
Not covered
Implants 50%
* DHMO plan only available in California, Arizona, Nevada, & Oregon
**Dental PPO Only ‐ Out‐of‐Network services are covered up to the 90th percentile of reasonable & customary. Member is responsible
for any charges above the allowable amounts when utilizing an Out‐of‐Network Dentist.
***Deductible waived
Vision Plan ‐ EyeMed
In‐ Network Out‐of‐Network
Exam Covered in full after $20 copay Up to $40
(once every 12 months)
Lenses (once every 12 months) Single,
Bifocal, Trifocal Covered in full after $20 copay Up to $30 / $50 / $70
Frames $110 allowance then 20% off Up to $77
(once every 24 months)
remaining balance
Contact Lenses ‐ elective Up to $110
(once every 12 months) $110 allowance
Contact Lenses – non‐elective Covered in full Up to $210
(once every 12 months)
To locate a provider, go to: www.eyemed.com or call 1‐866‐804‐0982, Insight network
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