Page 6 - Coast Sign Benefit Summary 2017 Final 9.26.17

Dental Options

DHMO Dental Plan: As a Premier Access PPO Dental Plan: With the Premier Access Preferred Provider
DHMO member, you are required to select a Organization (PPO) dental plan, you may visit a Premier Choice Network
general dentist to provide your dental care. You (PCN) dentist, a PPO dentist, or a non-network dentist. When you utilize a
will contact your general dentist for all of your PCN or a PPO dentist, your out-of-pocket expenses will be less. You may
dental needs, such as routine check‐ups and also obtain services using a non-network dentist; however, you will be
emergency situations. If specialty care is needed, responsible for the difference between the covered amount and the actual
your general dentist will provide the necessary charges and you may be responsible for filing claims.
referral. For covered procedures, you'll pay the
pre‐set copay or coinsurance fee described in your Premier Access
DHMO plan booklet. Please keep a copy of your PPO Dental Plan
booklet to refer to when utilizing your dental care.
This will show the applicable copays that apply to Plan Features
all of the dental services that are covered under PCN Network PPO Network Non-
this plan.
Network*
DHMO Plan Highlights:
• There is no office visit copay per visit Calendar Year Maximum $1,500
• There is no deductible to meet, and no annual Deductible (Annual)
dollar maximum. In most cases, no claim
forms to file, and no waiting period for - Individual / Family $25 / $75 $50 / $150 $50 / $150
coverage - Waived for Preventive Yes Yes Yes
• Members will be covered for most preventive Preventive (Plan Pays) 100% 100% 100%
services, including x‐rays and two exams and
cleanings per year Basic Services (Plan Pays) 90% 80% 80%
• Each family member chooses his or her own Major Services (Plan Pays) 60% 50% 50%
network dentist
• Orthodontia is covered at a copay for adults Orthodontia
and children -Adult and Child 50% up to $1,500 Lifetime Maximum
*Based on maximum allowable charge
Vision

The EyeMed vision plan provides professional vision care and high quality lenses and frames through
a broad network of optical specialists. You will receive richer benefits if you utilize a network
NOTE: provider. If you utilize a non‐network provider, you will be responsible to pay all charges at the time
EyeMed’s network of your appointment and will be required to file an itemized claim with EyeMed.
includes access to
independent EyeMed
ophthalmologists PPO Vision Plan

and optometrists,
Plan Features
as well as JC
Penney Optical, Network Non-Network
LensCrafters,
Pearle Vision, Examination Copay $10 Copay $30 Benefit
Sears Optical and Frequency 12 Months
Target Optical
retail stores. Materials Copay $25 Copay
Lenses Single Vision 100% $25 Benefit
Bifocal 100% $40 Benefit
Trifocal 100% $60 Benefit
Frequency 12 Months
Frames Allowance Up To $120 $60 Benefit

Frequency 24 Months
Contact Lenses Cosmetic / Elective Up To $105 $84 Benefit
Frequency 12 Months
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