Page 10 - Microsoft Word - CNLV Benefits Booklet Draft Revised 10.31.19 NON RETIREE.docx

DENTAL & VISION

A
Amount you paymount you pay
Amount you payAmount you pay
Type of serviceType of service
T
Dental Insurance Type of serviceype of service In InIn In- -- -NetworkNetwork
NetworkNetwork
In addition to protecting your smile, dental Calendar Year Deductible alendar Year Deductible
Calendar Year Deductible Calendar Year Deductible
C
insurance helps pay for dental care and includes Individual / Family Deductible $50 / $150
regular checkups, cleanings and X-rays. Several Deductible Waived if Preventive Yes
studies suggest that oral diseases, such as
periodontitis (gum disease), can affect other
P
Preventive SePreventive Servicesrvices
areas of your body—including your heart. Preventive Sereventive Servicesrvices
Receiving regular dental care can protect you Exam, Cleanings, Bitewing X-rays (limited to 2 per $0
and your family from the high cost of dental Benefit Period)
disease and surgery.
B
Basic ServicesBasic Services
Basic Servicesasic Services
Fillings, Sealants, Simple & Surgical Extractions, 20% after Deductible
Periodontics & Endodontics
Major Servicesajor Services
Major ServicesMajor Services
M
50% after Deductible
Oral Surgery, Bridges, Crowns & Dentures)
Maximum Benefit per Yearaximum Benefit per Year
Maximum Benefit per YearMaximum Benefit per Year
M $1,500 per person
O 50%
Orthodontia Orthodontia
Orthodontia rthodontia (Child Only up to age 19)
Orthodontia Lifetime Maximum $2,000
Find Dental providers at nd Dental providers at www.ameritas.www.ameritas.comcom
Find Dental providers at Find Dental providers at www.ameritas.www.ameritas.comcom
Fi
A
Amount you payAmount you pay
Vision Insurance T Amount you paymount you pay
Type of serviceype of service
Type of serviceType of service In InIn In- -- -NetworkNetwork
NetworkNetwork
Driving to work, reading a news article and
watching TV are all activities you likely perform E Once every 12 months
Eye Examye Exam
Eye ExamEye Exam
every day. Your ability to do all of these Lenses or Contact Lensesenses or Contact Lenses Once every 12 months
Lenses or Contact LensesLenses or Contact Lenses
L
activities, though, depends on your vision and F Once every 24 months
Framesrames
FramesFrames
eye health. Vision insurance can help you
maintain your vision as well as detect various
Eye Exam ye Exam CopayCopay / // / PrescriptionPrescription GlassesGlasses CopayCopay
Eye Exam Eye Exam CopayCopay PrescriptionPrescription GlassesGlasses CopayCopay
health problems. E $10 / $25*
*Deductible applies to a complete pair of
glasses or to frames, whichever is selected.
**The Costco allowance will be the wholesale Covered in Full
equivalent. Exam Exam (after copay)(after copay) Up to $150** Retail
Exam xam (after copay)(after copay)
E
F Allowance
Frames Frames (after copay)(after copay)
Frames rames (after copay)(after copay)
S
Single Vision Lenses ingle Vision Lenses (after copay)(after copay) Covered in Full
Single Vision Lenses Single Vision Lenses (after copay)(after copay)
B
Bifocal Lenses Bifocal Lenses (after copay)(after copay)
Bifocal Lenses ifocal Lenses (after copay)(after copay) Covered in Full
Trifocal Lenses rifocal Lenses (after copay)(after copay)
Trifocal Lenses Trifocal Lenses (after copay)(after copay)
T Covered in Full
L Lenticular Lensesenticular Lenses (afte(after copay)r copay) Covered in Full
Lenticular LensesLenticular Lenses (afte(after copay)r copay)
P See Lens Options
Progressive Lensesrogressive Lenses (after copay)(after copay)
Progressive LensesProgressive Lenses (after copay)(after copay)
ContactsContacts
C
Contactsontacts Covers up to $85.00
Fit & Follow up Exams Fit & Follow up Exams (after copay)(after copay) Covers up to $55
Fit & Follow up Exams Fit & Follow up Exams (after copay)(after copay)
Elective Elective (after copay)(after copay) Covers up to $150
Elective Elective (after copay)(after copay)
Medically Necessary Medically Necessary (after copay)(after copay) Covered in Full
Medically Necessary Medically Necessary (after copay)(after copay)
Fi
Find Vision providers atFind Vision providers at www.vsp.comwww.vsp.com
Find Vision providers atnd Vision providers at www.vsp.comwww.vsp.com
Please review the Dental & Vision Plan policies for complete information on coverage and exclusions.
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