Page 19 - HCSC2019EG

Benefit Contributions -Vision and Dental
17
FULL-TIME AND PART-TIME (30 OR MORE HOURS PER WEEK)
Dearborn National® Vision Care powered by EyeMedSM Monthly Contributions
PREFERRED
PREFERRED PLUS
Employee Contribution
Employee Contribution
Employee
$5.51
$8.93
Employee/Spouse
$9.92
$16.07
Employee/Children
$10.45
$16.99
Employee/Family
$16.52
$26.79
EyeMed is an independent company that administers the vision benefits for Dearborn National, which is a separate company that is solely responsible for the products and services they provide.
Dental Coverage
Options
Basic and Enhanced Dental options include a PPO network. You can see any dentist, but you will not be responsible for amounts over the scheduled allowance when you receive services from a PPO network dentist.
Dental Coverage Options
OPTION
DEDUCTIBLE
COVERED SERVICES
MAXIMUMs
Basic Coverage
$25 per person
$75 maximum per family
• 100% Preventive (no deductible) • 80% X-rays
• 80% Primary Services
• 80% Crowns
• 50% Prosthodontic Services • Orthodontics (not covered)
$1,000 per person
Enhanced Coverage
$50 per person
$150 maximum per family
• 100% Preventive (no deductible)
• 100% X-rays (no deductible)
• 80% Primary Services
• 80% Crowns
• 50% Prosthodontic Services (includes implants)
• 50% Orthodontics (up to lifetime maximum of $2,000 for children and adults)
$2,000 per person
Dental HMO (Chicago Metro)
None
Member responsible for copayments for certain services; Orthodontics – $1,000 copay for children and adults
$2,000 per person
Dental Coverage Monthly Contribution
BASIC PPO
ENHANCED PPO
DENTAL HMO (Chicago Metro)
Tier 1 $55,000 and under
Employee Contribution
Total Premium
Employee Contribution
Total Premium
Employee Contribution
Total Premium
Employee Only
$15
$29
$18
$34
$17
$40
Employee + Spouse
$28
$54
$35
$66
$33
$79
Employee + Children
$37
$70
$42
$80
$43
$103
Employee + Family
$54
$103
$64
$121
$62
$150
Tier 2 $55,001 and over
Employee Contribution
Total Premium
Employee Contribution
Total Premium
Employee Contribution
Total Premium
Employee Only
$17
$29
$20
$34
$20
$40
Employee + Spouse
$32
$54
$40
$66
$40
$79
Employee + Children
$41
$70
$47
$80
$52
$103
Employee + Family
$60
$103
$71
$121
$75
$150