Page 13 - Acadia 2024 Benefits Guide | Erlanger
P. 13
Your Path to Health
Dental Plans Vision Plan
Acadia offers you and your eligible dependents the opportunity Acadia offers you and your eligible dependents vision coverage
to enroll in dental coverage through Delta Dental of Tennessee. through VSP. To ind an in-network doctor or retail provider, visit
You have the option to enroll in either the Delta Dental of TN www.vsp.com or call 800.877.7195. Members enrolled in the
Value Plan or the Base Plan. As a member of the: VSP vision plan can create an account on www.vsp.com and
print an ID card. However, an ID card is not needed for services.
y Value Plan—you have access to only the Delta Dental PPO
network. OUT-OF-
y Base Plan—you have access to both the Delta Dental PPO BENEFIT PLAN IN-NETWORK NETWORK
and Delta Dental Premier networks.
Exam
You may be balance billed for seeing a non-network dentist, (every 12 months) $0 Up to $45
which means you will be responsible for any amount above Lenses
what the plan will pay. (every 12 months)
y Single Vision $10 copay Up to $30
VALUE PLAN BASE PLAN y Lined Bifocal $10 copay Up to $50
PROVISION PPO NETWORK PREMIER/PPO y Lined Trifocal $10 copay Up to $60
ONLY NETWORK y Lenticular $10 copay Up to $75
Annual Deductible Standard Progressive
(Individual/Family) $50/$150 $50/$150 Lenses
(every 12 months) Covered in full Up to $50
Is the Deductible Waived Yes Yes See plan document for
for Preventative Services? additional lens options
and discounts
Annual Maximum
(per person for all $500 $1,500 Frames $170 allowance Up to $50
services including (every 12 months)
preventative care) $145 allowance
Diagnostic and Contact Lenses for contacts;
Preventive: Includes Plan pays Plan pays (every 12 months— $20 copay for Up to $100
cleanings, luoride 100% 100% instead of glasses) a contact lens
treatments, and x-rays examination
Basic Services: Includes
illings, sealants, 20%*
periodontics, scaling and 20%*
root planing, and oral No (endo/
surgery perio/surgery)
Major Services: Includes
crowns, bridges and full No coverage 50%*
and partial dentures
Orthodontia: Children 50%*
Only (to end month of No coverage $1,500 lifetime
age 19) maximum
Note: Table relects employee portion of cost in-network. If
your provider is out of network, you may be responsible for the
amount that is over the Reasonable and Customary.
* After you meet the deductible
2024 Employee Beneits Guide | 13
Dental Plans Vision Plan
Acadia offers you and your eligible dependents the opportunity Acadia offers you and your eligible dependents vision coverage
to enroll in dental coverage through Delta Dental of Tennessee. through VSP. To ind an in-network doctor or retail provider, visit
You have the option to enroll in either the Delta Dental of TN www.vsp.com or call 800.877.7195. Members enrolled in the
Value Plan or the Base Plan. As a member of the: VSP vision plan can create an account on www.vsp.com and
print an ID card. However, an ID card is not needed for services.
y Value Plan—you have access to only the Delta Dental PPO
network. OUT-OF-
y Base Plan—you have access to both the Delta Dental PPO BENEFIT PLAN IN-NETWORK NETWORK
and Delta Dental Premier networks.
Exam
You may be balance billed for seeing a non-network dentist, (every 12 months) $0 Up to $45
which means you will be responsible for any amount above Lenses
what the plan will pay. (every 12 months)
y Single Vision $10 copay Up to $30
VALUE PLAN BASE PLAN y Lined Bifocal $10 copay Up to $50
PROVISION PPO NETWORK PREMIER/PPO y Lined Trifocal $10 copay Up to $60
ONLY NETWORK y Lenticular $10 copay Up to $75
Annual Deductible Standard Progressive
(Individual/Family) $50/$150 $50/$150 Lenses
(every 12 months) Covered in full Up to $50
Is the Deductible Waived Yes Yes See plan document for
for Preventative Services? additional lens options
and discounts
Annual Maximum
(per person for all $500 $1,500 Frames $170 allowance Up to $50
services including (every 12 months)
preventative care) $145 allowance
Diagnostic and Contact Lenses for contacts;
Preventive: Includes Plan pays Plan pays (every 12 months— $20 copay for Up to $100
cleanings, luoride 100% 100% instead of glasses) a contact lens
treatments, and x-rays examination
Basic Services: Includes
illings, sealants, 20%*
periodontics, scaling and 20%*
root planing, and oral No (endo/
surgery perio/surgery)
Major Services: Includes
crowns, bridges and full No coverage 50%*
and partial dentures
Orthodontia: Children 50%*
Only (to end month of No coverage $1,500 lifetime
age 19) maximum
Note: Table relects employee portion of cost in-network. If
your provider is out of network, you may be responsible for the
amount that is over the Reasonable and Customary.
* After you meet the deductible
2024 Employee Beneits Guide | 13
