Page 4 - 2019 Point Loma Credit Union Benefits Guide

Dental Insurance Vision Insurance

Whether your vision is 20/20 or less than perfect, everyone needs to
We are pleased to offer you a choice of 2 dental plans, a Dental HMO or
DPPO with United Concordia. The DHMO plan is a scheduled fee plan, receive regular vision care. Similar to a PPO plan, you may take
advantage of the highest level of benefit by receiving services from in-
covering Preventive, Basic, Major, and Orthodontic services. Please
refer to your copay schedule for more details. The DPPO chart gives network vision providers.
you a side-by-side look at how each type of service is covered when you
use in-network and out-of-network providers.
EyeMed In-Network Out-of-Network
Tips: Reimbursement

Be sure to ask your dental office to submit a pre-estimate plan to your Frequency Limits Exam: Once every 12 months
insurance carrier prior to receiving major dental work. Your insurance Lenses: Once every 12 months
carrier will provide an Explanation of Benefits illustrating services the Frames: Once every 12 months
insurance will cover or not cover and how much will be your
responsibility. Exam $20 copay Up to $40

It is important to bring your DHMO Copay Schedule to your dentist. Most Lenses
covered services will show a copayment alongside the service
Single Vision $20 copay Up to $30

Bifocal $20 copay Up to $50
United Concordia DHMO
Trifocal $20 copay Up to $70

ADA In-Network ONLY
Codes Frames $150 allowance + 20% Up to $105
off balance

Deductible (Individual/Family) None
Contact Lenses

Annual Benefit Maximum Unlimited Elective $150 allowance + 15% Up to $150
off balance
Prophylaxis (adult/child) 1110 No copay Necessary No charge Up to $210

Porcelain Crown fused to metal 2752 $110 copay

Root Planning - per quadrant 4341 $15 copay
Vision Value-Adds

Root Canal Therapy - molar 3330 $95 copay • Freedom Pass allows you to visit any Target or Sears Optical and
pick out any available frame and it’ll be covered-in-full.
Orthodontic Services 8080/8090 $1,500 copay / $2,000
(adult/child) copay • Members will receive a 20% discount on remaining balance at
participating providers beyond plan coverage; this does not
There’s not much paperwork in a DPPO if you stay in-network. You pertain to disposable contacts.
simply pay your co-payment or co-insurance up front when you visit
your dentist, and your dentist in turn sends claims directly to your • Save 15% off the retail price or 5% off the promotional price for
insurer. But, if you go out-of-network, you may need to pay the dentist LASIK or PRK procedures with an in-network provider.
in full yourself, and then submit the claim to your insurer to be
• Discounts on hearing aids and exams through Amplifon
reimbursed.

United Concordia DPPO

In-Network Out-of-Network
Basic Life/AD&D
Calendar Year Deductible $25 Individual $25 Individual
(Individual/Family) $75 Family $75 Family 100% COMPANY PAID — We provide full-time employees with Group
Term Life and Accidental Death & Dismemberment (AD&D) insurance
Calendar Year Annual $5,000 $5,000 through Mutual of Omaha in the amount of 1 times your annual
Benefit Max
compensation, up to a maximum benefit of $150,000. This benefit
provides valuable income protection in the case that you suffer a
Preventive Services No charge No charge
severe accident or loss of life. For a complete benefit summary, please
download the summary from the Benefits Website.
Basic Services Plan: 90%, You: 10% Plan: 80%, You: 20%
Major Services Plan: 60%, You: 40% Plan: 50%, You: 50%
Orthodontic Services Plan: 60%, You: 40% Plan: 60%, You: 40%

Orthodontic Lifetime Max $2,000 per person $2,000 per person

Pg. 3 | Point Loma Credit Union | Benefits Guide