Page 10 - Acadia 2021 Benefits Guide Erlanger
P. 10
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 NVA. To ind a NVA doctor or retail provider, visit
You have the option to enroll in either the Delta Dental of TN www.e-nva.com or call (800) 672.7723. You will receive an ID
Value Plan or the Base Plan. As a member of the: card from NVA.
• Value Plan – you have access to only the Delta Dental PPO
network Beneit Plan IN-NETWORK OUT-OF-
NETWORK
• Base Plan – you have access to both the Delta Dental PPO
and Delta Dental Premier networks Exam $0 copay Up to $50
(every 12 months)
You may be balance billed for seeing a non-network dentist,
which means that you will be responsible for the difference.
Lenses
(every 12 months)
VALUE PLAN BASE PLAN » Single Vision $10 copay Up to $50
PPO
PROVISION NETWORK PREMIER/ » Lined Bifocal $10 copay Up to $60
PPO
ONLY NETWORK » Lined Trifocal $10 copay Up to $70
» Lenticular $10 copay Up to $100
Annual Deductible
(Individual/Family) $50/$150 $50/$150 Progressive Lenses
(every 12 months)
Is the Deductible Waived Yes Yes
for Preventative Services? » Tier 1 $10 copay NA
» Tier 2 (Standard) $80 + $10 copay NA
Annual Maximum » Tier 3–4 (Premium) $100-$120 NA
(per person for all services $500 $1,500 *See plan document for + $10 copay
including preventative care) additional lens options
and discounts
Diagnostic and Preventive: Plan Pays Plan Pays
Includes cleanings, luoride $170 allowance
treatments, and x-rays 100% 100% Frames then 20% off Up to $100
(every 12 months) balance
Basic Services: Includes 20%*
illings, sealants,
periodontics, scaling and No (Endo/ 20%* $145 allowance Up to $105
root planing, and oral surgery Perio/Surgery) Contact Lenses for contacts;
(every 12 months – $50 contact Up to $50
instead of glasses) lens it/follow- contact lens
Major Services: Includes it/follow-up
crowns, bridges and full No Coverage 50%* up copay
and partial dentures
Extra Savings Available
50%* & Discounts
Orthodontia-Children Only No Coverage $1,500 lifetime sunglasses and laser through NVA Not Available
(to end month of age 19) maximum vision correction Doctors Only
Note: Table relects employee portion of cost in-network. Note: Diabetic Eyecare Plus Program included in-network
Please note that if your provider is out of network, you may be copay of $20 with services related to diabetic eye disease,
responsible for the amount that is over the Reasonable and glaucoma and age-related macular degeneration.
Customary.
*After you meet the deductible
10 | Erlanger Behavioral Health
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 NVA. To ind a NVA doctor or retail provider, visit
You have the option to enroll in either the Delta Dental of TN www.e-nva.com or call (800) 672.7723. You will receive an ID
Value Plan or the Base Plan. As a member of the: card from NVA.
• Value Plan – you have access to only the Delta Dental PPO
network Beneit Plan IN-NETWORK OUT-OF-
NETWORK
• Base Plan – you have access to both the Delta Dental PPO
and Delta Dental Premier networks Exam $0 copay Up to $50
(every 12 months)
You may be balance billed for seeing a non-network dentist,
which means that you will be responsible for the difference.
Lenses
(every 12 months)
VALUE PLAN BASE PLAN » Single Vision $10 copay Up to $50
PPO
PROVISION NETWORK PREMIER/ » Lined Bifocal $10 copay Up to $60
PPO
ONLY NETWORK » Lined Trifocal $10 copay Up to $70
» Lenticular $10 copay Up to $100
Annual Deductible
(Individual/Family) $50/$150 $50/$150 Progressive Lenses
(every 12 months)
Is the Deductible Waived Yes Yes
for Preventative Services? » Tier 1 $10 copay NA
» Tier 2 (Standard) $80 + $10 copay NA
Annual Maximum » Tier 3–4 (Premium) $100-$120 NA
(per person for all services $500 $1,500 *See plan document for + $10 copay
including preventative care) additional lens options
and discounts
Diagnostic and Preventive: Plan Pays Plan Pays
Includes cleanings, luoride $170 allowance
treatments, and x-rays 100% 100% Frames then 20% off Up to $100
(every 12 months) balance
Basic Services: Includes 20%*
illings, sealants,
periodontics, scaling and No (Endo/ 20%* $145 allowance Up to $105
root planing, and oral surgery Perio/Surgery) Contact Lenses for contacts;
(every 12 months – $50 contact Up to $50
instead of glasses) lens it/follow- contact lens
Major Services: Includes it/follow-up
crowns, bridges and full No Coverage 50%* up copay
and partial dentures
Extra Savings Available
50%* & Discounts
Orthodontia-Children Only No Coverage $1,500 lifetime sunglasses and laser through NVA Not Available
(to end month of age 19) maximum vision correction Doctors Only
Note: Table relects employee portion of cost in-network. Note: Diabetic Eyecare Plus Program included in-network
Please note that if your provider is out of network, you may be copay of $20 with services related to diabetic eye disease,
responsible for the amount that is over the Reasonable and glaucoma and age-related macular degeneration.
Customary.
*After you meet the deductible
10 | Erlanger Behavioral Health
