Page 4 - Luminex 2021 BLUE Triangles 12pg Guide w_Notices V5 - 1-12-2021

DENTAL &

VISION COVERAGE

DENTAL & VISION BENEFITS

DENTAL - DELTA DENTAL
BENEFIT CORE PLAN BUY-UP PLAN
Annual Calendar Year Maximum $1,000 $1,500
Calendar Year Deductible (Single/Family) $75/$225 $50/$150
Preventive Services
Oral Exams
X-rays No Charge No Charge
Cleanings Sealants not covered Sealants not covered
Fluoride Treatment
Basic Services
Fillings
Periodontal Services Deductible then 20% Deductible then 20%
Extractions
Endodontic Services
Major Services
Crowns
Prosthodontics Deductible then 50% Deductible then 50%
Partials
Orthodontia
Deductible N/A N/A
Orthodontic Treatment N/A 50%
Orthodontia Lifetime Maximum N/A $1,000
DENTAL BI-WEEKLY PER-PAYCHECK DEDUCTIONS
Employee Only $3.45 $6.04
Employee + Spouse $6.90 $12.07
Employee + Child(ren) $8.39 $14.88
Employee + Family $13.22 $23.44
VISION - UNITEDHEALTHCARE VISION

BENEFIT IN-NETWORK OUT-OF-NETWORK
Exam $20 copay Up to $40
Materials Copay (Frames, Lenses, Contacts) $20 N/A
Frequency (Exams/Lenses/Frames/Contacts) 12/12/24/12
$20 Material Copay then $130 Allowance, 30%
Frames Up to $45
discount applied to remaining balance
Lenses
Single $20 Material Copay Up to $40
Lined Bifocal $20 Material Copay Up to $60
Lined Trifocal $20 Material Copay Up to $80
Scratch Coating Standard Coating No Charge N/A
Contact Lenses Instead of Glasses
$130 allowance, additional 30% discount may be
Elective conventional lenses Up to $130
applied to remaining balance
Elective Disposable Lenses $130 allowance Up to $130
Non-Elective Contact Lenses No Charge Up to $210
VISION BI-WEEKLY PER-PAYCHECK DEDUCTIONS
Employee Only $0.55
Employee + Spouse $3.43
Employee + Child(ren) $3.72
Family $5.69

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