Page 6 - VSolvit 2021 Employee Benefits_Final
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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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