Page 19 - Demo

Benefit Contributions - Vision and Dental
FULL-TIME AND PART-TIME (30 OR OR MORE HOURS PER WEEK)
Dearborn National® Vision Care powered by EyeMedSM
Monthly Contributions PREFERRED PREFERRED PREFERRED PREFERRED PLUS
Employee Employee Contribution Contribution Employee Employee Contribution Contribution Employee $5 51 $8 93
17
Dental
Coverage Monthly Contribution Employee/Spouse Employee/Children Employee/Family $9 92 $16 07 $10 45
$16 99 $16 52 $26 79
EyeMed is is is an an independent company that administers the vision benefits for Dearborn National which is is a a a a a a separate company that is is solely responsible for the the products and services they provide BASIC PPO Employee Contribution ENHANCED PPO Tier 1 $55 000 and under Total Total Employee Total Total Premium
Premium
Contribution Premium
Premium
DENTAL HMO (Chicago Metro)
$54
Employee Contribution $103 $64 $121
Tier 2 $55 001 and over Total Total Employee Total Total Premium
Premium
Contribution Premium
Premium
$62
Employee Contribution $150 Total Premium
OPTION
Basic Coverage Enhanced Coverage Dental
HMO (Chicago Metro)
DEDUCTIBLE
$25 per person
$75 maximum per family
$50 per person
$150 maximum per family
None
Dental
Coverage Options COVERED SERVICES
• 100% Preventive (no deductible) • 80% X-rays
• 80% Primary Services
• 80% Crowns
• 50% Prosthodontic Services
• Orthodontics (not covered)
• 100% Preventive (no deductible) • 100% X-rays
(no deductible) • 80% Primary Services
• 80% Crowns
• 50% Prosthodontic Services
(includes implants)
• 50% Orthodontics (up to lifetime maximum of $2 000 for children and adults)
Member responsible for copayments for certain services Orthodontics – $1 000 copay for children and adults MAXIMUMs
$1 000 per per person
$2 000 per per person
$2 000 per per person
Dental
Coverage Options Basic and Enhanced Dental
options include a PPO network You can see any dentist but you will not be responsible for amounts over the scheduled allowance when you receive services from a PPO network dentist Employee Only Employee + Spouse Employee + Children Employee + Family Employee Only Employee + Spouse Employee + Children Employee + Family $15 $29 $18 $34 $28 $54
$35 $66 $37 $70 $42 $80
$40 $17 $29 $20 $34 $32 $54
$40 $66 $41 $70 $47 $80
$60 $103 $71 $121
$20 $40 $40 $79 $52 $103 $75 $150 Employee Contribution $17 $33 $79 $43 $103 Total Premium