Page 18 - 2016 Open Enrollment
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Vision
Vision
Eye doctors detect problems in vision, overall eye health, and signs of
other health conditions like diabetic eye disease, high blood pressure, and
high cholesterol. We know your eyesight is precious to you, so we provide
vision beneits to make sure your trip to the eye doctor is reasonably
priced.
We partner with Delta Dental of IL to offer you comprehensive vision
coverage. Keep in mind, the information in the chart provided is a
summary only. Please refer to your Certiicate of Coverage (COC) for
complete details of plan beneits, limitations, and exclusions on OTL.
Visit www.deltadentalil.com.
In-Network Out-of-Network
Vision Exam
Exam Copay $20 copay $35 allowance
Lenses
Single Lens $20 copay $25 allowance
Bifocal Lens $20 copay $40 allowance
Trifocal Lens $20 copay $55 allowance
Frames
Frame Beneit $100 allowance, 20% off $50 allowance
balance over $100
Contact Lenses
Conventional $0 copay, $80 allowance, 15% $64 allowance
off balance over $80
Disposable $0 copay, $80 allowance, plus $64 allowance
balance over $80
Bi-Weekly Rates Visually Required $0 copay, paid-in-full $200 allowance
Associate Only $2.66 Frequency
Associate + Spouse $5.20 Exams 12 months 12 months
Associate + Child(ren) $5.82 Lens 12 months 12 months
Family $8.40 Contacts 12 months 12 months
(in lieu of glasses)
Frames 24 months 24 months
First Busey Corporation
Vision
Vision
Eye doctors detect problems in vision, overall eye health, and signs of
other health conditions like diabetic eye disease, high blood pressure, and
high cholesterol. We know your eyesight is precious to you, so we provide
vision beneits to make sure your trip to the eye doctor is reasonably
priced.
We partner with Delta Dental of IL to offer you comprehensive vision
coverage. Keep in mind, the information in the chart provided is a
summary only. Please refer to your Certiicate of Coverage (COC) for
complete details of plan beneits, limitations, and exclusions on OTL.
Visit www.deltadentalil.com.
In-Network Out-of-Network
Vision Exam
Exam Copay $20 copay $35 allowance
Lenses
Single Lens $20 copay $25 allowance
Bifocal Lens $20 copay $40 allowance
Trifocal Lens $20 copay $55 allowance
Frames
Frame Beneit $100 allowance, 20% off $50 allowance
balance over $100
Contact Lenses
Conventional $0 copay, $80 allowance, 15% $64 allowance
off balance over $80
Disposable $0 copay, $80 allowance, plus $64 allowance
balance over $80
Bi-Weekly Rates Visually Required $0 copay, paid-in-full $200 allowance
Associate Only $2.66 Frequency
Associate + Spouse $5.20 Exams 12 months 12 months
Associate + Child(ren) $5.82 Lens 12 months 12 months
Family $8.40 Contacts 12 months 12 months
(in lieu of glasses)
Frames 24 months 24 months
First Busey Corporation
