Page 12 - Acadia 2023 Benefits Guide | Cascade
P. 12
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,
You have the option to enroll in either the Delta Dental of TN visit www.vsp.com or call 800.877.7195. After January 1, 2023,
Value Plan or the Base Plan. As a member of the: members enrolled in the VSP vision plan can create an account
on www.vsp.com and print an ID card. However, an ID card is
y Value Plan—you have access to only the Delta Dental PPO not needed for services.
network.
y Base Plan—you have access to both the Delta Dental PPO OUT-OF-
and Delta Dental Premier networks. BENEFIT PLAN IN-NETWORK NETWORK
You may be balance billed for seeing a non-network dentist, Exam
which means you will be responsible for any amount above (every 12 months) $0 Up to $45
what the plan will pay. Lenses
(every 12 months)
VALUE PLAN BASE PLAN y Single Vision $10 copay Up to $30
PROVISION PPO NETWORK PREMIER/PPO y Lined Bifocal $10 copay Up to $50
ONLY NETWORK y Lined Trifocal $10 copay Up to $60
Annual Deductible y Lenticular $10 copay Up to $75
(Individual/Family) $50/$150 $50/$150 Standard Progressive
Lenses
Is the Deductible Waived Yes Yes (every 12 months) Covered in full Up to $50
for Preventative Services? See plan document for
additional lens options
Annual Maximum and discounts
(per person for all
services including $500 $1,500 Frames $170 allowance Up to $50
preventative care) (every 12 months)
Diagnostic and $145 allowance
Preventive: Includes Plan pays Plan pays Contact Lenses for contacts;
cleanings, luoride 100% 100% (every 12 months— $20 copay for Up to $100
treatments, and x-rays instead of glasses) a contact lens
Basic Services: Includes 20%* examination
illings, sealants,
periodontics, scaling and No (endo/ 20%*
root planing, and oral perio/surgery)
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
12 | Cascade Behavioral 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,
You have the option to enroll in either the Delta Dental of TN visit www.vsp.com or call 800.877.7195. After January 1, 2023,
Value Plan or the Base Plan. As a member of the: members enrolled in the VSP vision plan can create an account
on www.vsp.com and print an ID card. However, an ID card is
y Value Plan—you have access to only the Delta Dental PPO not needed for services.
network.
y Base Plan—you have access to both the Delta Dental PPO OUT-OF-
and Delta Dental Premier networks. BENEFIT PLAN IN-NETWORK NETWORK
You may be balance billed for seeing a non-network dentist, Exam
which means you will be responsible for any amount above (every 12 months) $0 Up to $45
what the plan will pay. Lenses
(every 12 months)
VALUE PLAN BASE PLAN y Single Vision $10 copay Up to $30
PROVISION PPO NETWORK PREMIER/PPO y Lined Bifocal $10 copay Up to $50
ONLY NETWORK y Lined Trifocal $10 copay Up to $60
Annual Deductible y Lenticular $10 copay Up to $75
(Individual/Family) $50/$150 $50/$150 Standard Progressive
Lenses
Is the Deductible Waived Yes Yes (every 12 months) Covered in full Up to $50
for Preventative Services? See plan document for
additional lens options
Annual Maximum and discounts
(per person for all
services including $500 $1,500 Frames $170 allowance Up to $50
preventative care) (every 12 months)
Diagnostic and $145 allowance
Preventive: Includes Plan pays Plan pays Contact Lenses for contacts;
cleanings, luoride 100% 100% (every 12 months— $20 copay for Up to $100
treatments, and x-rays instead of glasses) a contact lens
Basic Services: Includes 20%* examination
illings, sealants,
periodontics, scaling and No (endo/ 20%*
root planing, and oral perio/surgery)
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
12 | Cascade Behavioral Health
