Page 5 - Coast Sign Benefit Summary 2017 - Non- CA - sent 9.26.17

Dental Option

PPO Dental Plan: With the Premier Access Preferred Provider Organization (PPO) dental plan, you may visit a Premier Choice
Network (PCN) dentist, a PPO dentist, or a non-network dentist. When you utilize a PCN or a PPO dentist, your out-of-pocket
expenses will be less. You may also obtain services using a non-network dentist; however, you will be responsible for the difference
between the covered amount and the actual charges and you may be responsible for filing claims.

Premier Access

PPO Dental Plan

Plan Features
PCN Network PPO Network Non-Network*

Calendar Year Maximum $1,500
Deductible (Annual)
- Individual / Family $25 / $75 $50 / $150 $50 / $150
- Waived for Preventive Yes Yes Yes

Preventive (Plan Pays) 100% 100% 100%
Basic Services (Plan Pays) 90% 80% 80%
Major Services (Plan Pays) 60% 50% 50%

Orthodontia

*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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