Page 19 - Lyon Benefits Guide 01-18 CA - FINAL

[EMPLOYEE BENEFITS]

DENTAL INSURANCE VISION INSURANCE

METLIFE | DHMO VSP | PPO
With the Dental Health Maintenance Organization (DHMO) plan through MetLife, you are required to select a general dentist who is The VSP Vision plan provides professional vision care and high-quality lenses and frames through a broad network of optical specialists.
a member of the network to provide your dental care. You will contact your general dentist for all of your dental needs, such as routine You will receive richer benefits if you utilize a network provider. If you utilize a non-network provider, you will be responsible to pay all
check-ups and emergency situations. If specialty care is needed, your general dentist will provide the necessary referral. For covered charges at the time of your appointment and will be required to file an itemized claim with VSP Vision.
procedures, you’ll pay the pre-set copay or coinsurance fee described in your DHMO plan booklet. Please keep a copy of your booklet
to refer to when utilizing your dental care. This will show the applicable copays that apply to all of the dental services that are covered VSP has the largest network of private-practice eye care doctors in the industry. VSP’s network includes 50,000 access points nationwide.
under this plan. VSP also contracts with Costco Optical, Eye Care Centers of America / Visionworks, and other affiliate retail providers. Please note,
benefits may vary at affiliate locations.
METLIFE | PPO

With the MetLife Preferred Provider Organization (PPO) dental plan, you may visit a PPO dentist and benefit from the negotiated rate VSP
or visit a non-network dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less. You may also obtain services PPO
using a non-network dentist; however, you will be responsible for the difference between the covered amount and the actual charges and Network Name Choice Non-Network
you may be responsible for filing claims.
VISION BENEFITS
Copay
METLIFE METLIFE • Examination $10 Copay N/A
DHMO PPO • Materials $10 Copay N/A
Network Name Dental HMO / Managed Care PDP Plus Non-Network Examination (Every 12 Months) No Charge after Copay Up to $45 Reimbursement
DENTAL BENEFITS Lenses (Every 12 Months)
Calendar Year Maximum Benefit Unlimited $1,500 • Single Vision No Charge after Copay Up to $30 Reimbursement
Annual Deductible • Bifocal No Charge after Copay Up to $50 Reimbursement
• Individual None $50 • Trifocal No Charge after Copay Up to $65 Reimbursement
• Family None $150 • Polycarbonate (Children) No Charge after Copay Not Covered
Preventive Services 100% for Most Services No Charge No Charge (UCR) • Standard Progressive $55 Copay Up to $50 Reimbursement
Exams, X-Rays, Cleanings Balance Billing May Apply • Premium Progressive $95-$105 Copay
$150-$175 Copay
Basic Services See Copay Schedule Ded, 20% Ded, 20% (UCR) • Custom Progressive 20% Discount Over Allowance
Other Lens Enhancements
•
Fillings, Endodontics, Periodontics Balance Billing May Apply
$130 Allowance,
Major Services See Copay Schedule Ded, 50% Ded, 50% (UCR) Frames (Every 24 Months) $150 Featured Frame Allowance, Up to $70 Reimbursement
Crowns, Oral Surgery, Prosthodontics Balance Billing May Apply 20% Discount Over Allowance
Orthodontia
• Covered Members Children & Adults Children & Adults Contact Lenses (Every 12 Months) (in lieu of frames and lenses)
• Copay $1,450 Copay N/A $130 Allowance Up to $105 Reimbursement
• Coinsurance N/A 50% Extra Savings
• Lifetime Benefit Maximum N/A $1,500 • Glasses and Sunglasses Extra $20 Featured Frame Allowance at Not Covered
www.vsp.com/specialoffers,
20% Savings on Additional Glasses
• Retinal Screening $39 Copay Maximum Not Covered
• Laser Vision Correction Average 15% off Regular Price or Not Covered
FINDING A DENTAL PROVIDER 5% off Promotional Price
Go to www.metlife.com/dental. Select “Find a Dentist” and enter your zip code.
• DHMO: Refer to the “Dental HMO / Managed Care” network and the “SGX85” plan when prompted.
• PPO: Refer to the “PDP Plus” network when prompted.
FINDING A VISION PROVIDER
Go to www.vsp.com. Refer to the “Choice” network when prompted.

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