Page 12 - 2013 Allied Printing Benefit & Notices

Allied Printing Co., Inc. 2013

Dental Coverage

Allied Printing Guardian PPO Dental Plan The is only a partial list of common dental services. Your certificate of
benefits will show exactly what is covered and excluded
Member’s Responsibility (copays and dollar maximums) In Network Out of Network
Copays
- Class I – Preventive services None None
- Class II – Basic Care services 10% of approved amount 20% of approved amount
- Class III – Major Care services 40% of approved amount 50% of approved amount
- Class IV – Orthodontic services Not Covered Not Covered
Dollar Maximums
- Annual Maximum (for Class I, II and III services) $ 750 per member
- Lifetime Maximum (for Class IV services) n/a
Class I – Preventive Services
Oral Exams 100% 100%
X-rays 100% 100%
Dental prophylaxis (teeth cleaning) 100% every 6 months 100% every 6 months
Pit and fissure sealants – for members age 16 and younger 100% 100%
Fluoride treatment – for members age 19 and younger 100% 100%
Class II – Basic Care Services
Fillings – permanent teeth 90% 80%
Recementation of crowns, veneers, inlays, onlays & bridges 90% 80%
Oral surgery including extractions 90% 80%
Root canal treatment – permanent tooth 90% 80%
Scaling and root planing 90% 80%
Anesthesia 90% 80%
Repairs and adjustments of a partial or complete denture 90% 80%
Relining or rebasing of a partial or complete denture 90% 80%
90%
Periodontic maintenance DRAFT 80%
Class III – Major Care Services
Inlays, onlays and veneer restorations – permanent teeth 60% 50%
Removal dentures (complete or partial) 60% 50%
Bridges (fixed partial dentures) 60% 50%
Single Crowns 60% 50%

Vision Coverage

Allied Printing Guardian Designer Vision Plan Davis Vision Network Provider Non-Davis Network Provider
DAVIS NETWORK PROVIDERS INCLUDE WAL-MART®/JCPENNEY®/ SEARS®/ TARGET®/ SAM’S CLUB® & PEARLE®.
Member’s Responsibilities (copays) SERVICE FREQEUNCIES – EVERY CALENDAR YEAR
Eye Exam $10 copay Amount Over $50
Single Vision Lenses $10 copay Amount Over $48
Lined Bifocal Lenses $10 copay Amount Over $67
Lined Trifocal Lenses $10 copay Amount Over $86
Frames 80% of Amount Over $120* Amount Over $48
Contact Lenses (Elective & Conventional) 85% of Amount Over $120* Amount Over $105
Contact Lenses (Planned replacement &
85% of Amount Over $120* Amount Over $105
Disposable)
Contact Lenses (Medically Necessary) $10 copay Amount Over $210
This is only a partial list of services. Your certificate of benefits will show exactly what is covered and excluded.
Dependent Age Limits – 20 years of age (26 years of age for student)
Benefit includes coverage for glasses or contact lenses, not both
Frames from the Fashion or Designers collections are covered in full in excess of plan’s material copay, if applicable. Framed from the Premier collection are
covered in full in excess of a $25 copay applied in addition to the plan’s material copay, if applicable. Frames from a network provider that are not in the
collections are covered up to the plan’s retail allowance in excess of the plan’s material copay, if applicable.

Contact lenses from Davis Vision’s Collection are available at most provate practice locations with Full Feature and Material Only plans. Contact from the
collection are covered in full including fittings ans evaluation, in excess of the plans material copay. Elective contacts are not part of the Collection are
covered up to the plan’s elective contact lenses allowance and the materials copay is waived.

*Due to lower prices available at Wal-Mart and Sam’s Club locations, discounts do not apply. Members will pay 100% of the amount over their allowances
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