Page 9 - Volcom Benefit Summary 2017 National Version 1

DENTAL OPTIONS

CIGNA
Plan Features DPPO
Network DPPO Network Non-Network
Calendar Year Maximum Benefit $1,500
Annual Deductible
Individual $50 $75
Family $150 $225
Office Visit Copay N/A N/A
Preventive Services (Plan Pays) 100% 100% UCR
Deductible Waived Yes Yes
Basic Services (Plan Pays) 90% 80% UCR
Oral Surgery (Plan Pays) 90% 80% UCR
Major Services (Plan Pays) 60% 50% UCR
Orthodontia
Children 50% with $1,500 Lifetime Maximum
Adults 50% with $1,500 Lifetime Maximum

H FINDING A DENTAL PROVIDER:

Go to www.cigna.com or call (800) 244-6224 to find a provider near you. Refer to the “Cigna Dental
PPO or EPO” dental plan when prompted.

VISION

UNITED HEALTHCARE
Plan Features Vision
Network Network Non-Network
Deductible $10 Exam / $25 Materials
Examination (Every 12 Months) 100% $40 Benefit
Lenses (Every 12 Months)
Single Vision 100% $40 Benefit
Bifocal 100% $60 Benefit
Trifocal 100% $80 Benefit
Frames (Every 24 Months) $130 Benefit $45 Benefit
Contact Lenses (Every 12 Months)
(in lieu of frames and lenses)
Cosmetic / Elective $125 Benefit $125 Benefit
Visually Necessary 100% $210 Benefit

H FINDING A VISION PROVIDER:

Go to www.myuhcvision.com or call (800) 638-3120 to find a provider near you.

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