5-Attachment B Current Dental and Vision Plan Summaries.pdf
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- Solicitation number
- LCSD10052026
- Issued by
- Utah
About this file
This document is a current benefits plan summary for Logan City School District, detailing the existing dental and vision coverage provided to employees. The dental plan, administered by Samera Health (a product of Town & Country Life Insurance Co.), operates on a plan year from September 1 through August 31 with Group Number LSDT09012023. The plan covers diagnostic and preventive services at 100% in-network, basic services at 70% after a $75 individual or $225 family deductible, major services at 50% after deductible, with a $1,000 maximum annual benefit. Preventive care includes two routine exams and cleanings per plan year with no waiting period, while major services such as crowns and dentures are subject to specific frequency limitations. The vision plan, designated Silver E150, provides coverage through any provider with annual benefits including an eye exam covered up to plan allowance, up to $150 for frames once per plan year, up to $75 for lenses, and up to $100 for lens options, with contact lens coverage as an alternative to glasses. Both plans specify coverage exclusions, frequency limitations, and coordination of benefits provisions.
The document serves as an attachment to the Employee Benefits Consulting and Insurance Brokerage Services RFP for Logan City School District and represents the incumbent plans against which proposing firms will likely benchmark their recommendations. Samera Health may be contacted at 435-563-0613 or Info@samerahealth.com for additional plan details, with dental claims submitted to Smithfield, Utah 84335 and vision claims processed through www.samerahealth.com/claim-reimbursement. The summary explicitly notes that it does not describe all plan terms and conditions, with the complete plan certificate serving as the definitive reference document. This attachment provides RFP respondents with comprehensive baseline information regarding current employee benefits structure, enabling comparison and evaluation of alternative benefit proposals.
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ATTACHMENT B
CURRENT DENTAL AND VISION PLAN SUMMARIES
Samera Health
Logan City School District - Employee Benefits Consulting and Insurance Brokerage Services RFP a product of Town & Country Life Insurance Co.
BENEFITS IN-NETWORK NON-NETWORK*
MAXIMUM ANNUAL BENEFIT
DEDUCTIBLE
DIAGNOSTIC/PREVENTIVE
Exams, X-rays, Cleanings
BASIC SERVICES
Restorations, Extractions, Oral Surgery
Endodontics, Periodontal Services
MAJOR SERVICES
Crowns, Dentures, Bridges
ORTHODONTIA
NA NA NA
LIFETIME ORTHO MAXIMUM
AD: AFTER DEDUCTIBLE
*Member will be responsible for amounts billed by non-participating providers in excess of maximum allowable fee.
COVERAGE / PROVISIONS / EXCLUSIONS:
Bone Grafts (D7953)
Composites (fillings):
Coordination of Benefits
Crowns
Full Mouth Debridement (D4355)
Impacted Wisdom Teeth & Assoc Anes
Implants
Limited Oral Exam (D0140)
Missing Tooth Clause
Nitrous No Coverage
Occlusal Guards
Panoramic & Bitewing same day?
Perio Evaluation (D0180) No Coverage
Sealants
Space Maintainers
FREQUENCIES*:
Bitewings
Exam (D0120, D0150)
Filling Replacement
Fluoride (D1206 or D1208)
Major Replacement
Panoramic or Full Mouth
Periapical X-rays
Perio Maintenance
Prophy (Cleaning)
Scaling & Root Planing (D4341)
*Additional frequencies may apply to other procedures not listed on this benefit summary. Please refer to the certificate for more details.
Samera Health Phone: 435-563-0613
PO BOX 126 Fax: 435-563-4035
Email: Info@samerahealth.com
Payor ID U8053 - no electronic attachments
For IN-NETWORK benefits:
6.25
NA
No Coverage
Standard Coordination of Benefits apply
MAJOR - paid on either seat or prep date. Downgrades to base metal.
No Coverage
BASIC - Extraction / BASIC - Anesthesia
No Coverage - Plan pays ADA codes for the Crown
2 times per plan year - anytime, up to age 19 www.samerahealth.com
2 times per plan year - D4910, D4346, D1110 all share frequency limits
1 time per 5 years and unserviceable
1 time per 36 months
6 times per plan year
2 times per plan year - anytime
1 time per 36 months - all quads allowed same day, 4MM+pocket depth required.
LOGAN CITY SCHOOL DISTRICT (Grp #: LSDT09012023)
BASIC - not downgraded to amalgam (silver filling)
Plan Year: September 1 - August 31
No Coverage
$1,000
$75/Person or $225/Family
No Waiting Period
100% 70% of maximum allowable fee
No Waiting Period
80% AD 70% of maximum allowable fee AD
No Waiting Period
50% AD 40% of maximum allowable fee AD
NA
NOTE: This Summary does not describe all terms, conditions and limitations. Refer to your Plan Certificate or contact your Benefits Manager for more details.
In the case of a discrepancy, the Plan Certificate applies. This summary does not guarantee payment.
DIAGNOSTIC / PREVENTIVE - combines with D0120 and D0150
No Coverage for teeth missing prior to effective date. Waived after 36 months.
PREVENTIVE - once per lifetime
Please visit Cache Premier Dental Network - www.samerahealth.com - for a list of participating providers and benefit summaries
To receive maximum discounts and in-network benefits, please use the Cache Premier dental network.
DENTAL CLAIMS ADDRESS AND CUSTOMER SERVICE:
Smithfield, UT 84335
Not allowed same day - if done, will convert to Full Mouth.
PREVENTIVE - to age 17, non-decayed molars only, once per lifetime
2 times per plan year - anytime
1 surface per 24 months - multiple surfaces on same tooth/same day will combine
2 times per plan year - anytime http://www.samerahealth.com/ http://www.samerahealth.com/ http://www.samerahealth.com/ http://www.samerahealth.com/
Logan City School District
Vision Plan - SILVER E150
BENEFITS
EYE EXAM
FRAME ALLOWANCE
One frame per plan year
(when used with prescription lenses)
LENS
Single Vision
Bifocal
Trifocal
Progressive
LENS OPTIONS
Polycarbonate
High Index
Photochromic
Polarized/Laminated
UV Protection
Solid Tints & Dyes
Scratch Resistance Coating
Anti-Reflective Coating
CONTACTS
Elective Contacts (in Lieu of Glasses)
LASIK
FREQUENCIES
Exam
Lens
Frames
Contacts
CLAIMS & CUSTOMER SERVICE
Submit completed claim form with an itemized receipt:
By Mail: By Fax: By Email:
Samera Health (435) 563-4035 vision@Samerahealth.com
PO Box 126
Smithfield UT 84335
(435) 563-0613
NETWORK:
7.25
Samera Health, a product of Town & Country Life Insurance Co.
By Electronic Device:
www.samerahealth.com/claim-reimbursement
Members may also access Cache Premier Vision to find providers who will offer a discount and submit a claim on the member's behalf.
You may locate Cache Premier Vision providers at www.samerahealth.com/find-care
NOTE: This Summary does not describe all terms, conditions and limitations. Refer to your plan certificate and policy or contact your Benefits Manager for more details. In the case of a discrepancy, the Plan Policy/Certificate applies.
ANY PROVIDER
once every plan year once every plan year
Allowances listed are one-time use benefits; no remaining balances carried forward.
Plan pays up to $150 for one frame
Eyeglass Exam or Contact Exam
Plan pays up to $150 once every plan year
Plan pays up to $50 for one exam
Members may use ANY provider and receive the benefits stated above by submitting an itemized receipt.
Plan Year: SEPTEMBER 1 thru AUGUST 31
Plan pays up to $75 for one pair of lens
Combined LENS OPTION benefit.
Plan pays up to $100
Lasik Eye Correction Surgery Members on any Samera Health policy can receive up to a
$1200 discount on Lasik procedures at Hoopes Vision.
(in lieu of glasses) once every plan year
Discount Benefit Only http://www.samerahealth.com/claim-reimbursement http://www.samerahealth.com/claim-reimbursement
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