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

[EMPLOYEE BENEFITS]

DENTAL INSURANCE VISION INSURANCE

METLIFE | PPO VSP | PPO
With the MetLife Preferred Provider Organization (PPO) dental plans, you may visit a PPO dentist and benefit from the negotiated rate The VSP Vision plan provides professional vision care and high-quality lenses and frames through a broad network of optical specialists.
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 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
using a non-network dentist; however, you will be responsible for the difference between the covered amount and the actual charges and charges at the time of your appointment and will be required to file an itemized claim with VSP Vision.
you may be responsible for filing claims.
VSP has the largest network of private-practice eye care doctors in the industry. VSP’s network includes 50,000 access points nationwide.
METLIFE METLIFE VSP also contracts with Costco Optical, Eye Care Centers of America / Visionworks, and other affiliate retail providers. Please note,
LOW PPO HIGH PPO benefits may vary at affiliate locations.
Network Name PDP Plus Non-Network PDP Plus Non-Network
VSP
DENTAL BENEFITS PPO
Calendar Year Maximum Benefit $1,500 $1,000 $1,500 Network Name Choice Non-Network
Annual Deductible
• Individual $0 $100 $50 VISION BENEFITS
• Family $0 $300 $150 Copay
Preventive Services No Charge Ded, 30% (UCR) No Charge No Charge (UCR) • Examination $10 Copay N/A
Exams, X-Rays, Cleanings Balance Billing Balance Billing • Materials $10 Copay N/A
May Apply May Apply Examination (Every 12 Months) No Charge after Copay Up to $45 Reimbursement
Basic Services 10% Ded, 40% (UCR) Ded, 20% Ded, 20% (UCR) Lenses (Every 12 Months)
Fillings, Endodontics, Periodontics Balance Billing Balance Billing • Single Vision No Charge after Copay Up to $30 Reimbursement
May Apply May Apply • Bifocal No Charge after Copay Up to $50 Reimbursement
Major Services 40% Ded, 70% (UCR) Ded, 50% Ded, 50% (UCR) • Trifocal No Charge after Copay Up to $65 Reimbursement
Crowns, Oral Surgery, Balance Billing Balance Billing • Polycarbonate (Children) No Charge after Copay Not Covered
Prosthodontics May Apply May Apply • Standard Progressive $55 Copay Up to $50 Reimbursement
Orthodontia • Premium Progressive $95-$105 Copay
• Covered Members Children & Adults Children & Adults Children & Adults • Custom Progressive $150-$175 Copay
• Copay N/A N/A N/A • Other Lens Enhancements 20% Discount Over Allowance
• Coinsurance 50% 60% 50% Frames (Every 24 Months) $130 Allowance, Up to $70 Reimbursement
• Lifetime Benefit Maximum $1,500 $1,000 $1,500 $150 Featured Frame Allowance,
20% Discount Over Allowance
Contact Lenses (Every 12 Months) (in lieu of frames and lenses)
$130 Allowance Up to $105 Reimbursement
FINDING A DENTAL PROVIDER Extra Savings
Go to www.metlife.com/dental. Select “Find a Dentist” and enter your zip code. Refer to the “PDP Plus” network • Glasses and Sunglasses Extra $20 Featured Frame Allowance at Not Covered
when prompted. 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
5% off Promotional Price

FINDING A VISION PROVIDER
Go to www.vsp.com. Refer to the “Choice” network when prompted.

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