Page 14 - Volcom Benefit Summary 2019 Hawaii

DENTAL

KAISER PERMANENTE
Plan Features HDS PPO
Network PPO Network Non-Network
Calendar Year Maximum Benefit Children: Unlimited / Adults: $1,200
Annual Deductible
Individual None None
Family None None
Preventive Services (Plan Pays)
Exams, Cleanings and Bitewing X-Rays 100% 100% Fee Schedule
Full Mouth X-Rays, Fluoride, Space Maintainers 70% 70% Fee Schedule
Restorative Services (Plan Pays)
Oral Surgery, Endodontics, Periodontics, Fillings 70% 70% Fee Schedule
Crowns 50% 50% Fee Schedule
Major Services (Plan Pays)
Bridges, Dentures 50% 50% Fee Schedule
Orthodontia Not Covered

H FINDING A DENTAL PROVIDER:
Kaiser uses the Delta Dental Hawaii Dental Services (HDS) provider network. Login to
www.hawaiidentalservice.com or call (808) 529-9248 (Oahu) or (800) 272-7204 (Neighboring Islands).

VISION

VSP
Plan Features Vision
Network Network Non-Network
Deductible $10 Exam / $25 Materials
Examination (Every 12 Months) 100% $45 Benefit
Lenses (Every 12 Months)
Single Vision 100% $30 Benefit
Bifocal 100% $50 Benefit
Trifocal 100% $65 Benefit
Frames (Every 24 Months) $130 Benefit $70 Benefit
Contact Lenses (Every 12 Months)
(in lieu of frames and lenses)
Cosmetic / Elective $130 Benefit $105 Benefit

FINDING A VISION PROVIDER:
Go to www.vsp.com or call (800) 877-7195 to find a provider near you: VSP Choice network.

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