SECHQ1-15-R-0001_Supplemental_Health_Benefits_Program_-_Attachment_2_-_Dental_and_Vision_Minimums_Matrix.pdf

Dental and Vision Insurance Plan

Minimum Requirements

Offeror's Plan (Please fill in how the plan meets or exceeds the minimum requirements)

Out-of-Area Coverage Yes

Use of Network Dentist Required No

Pretreatment Estimate Required $500

Annual Maximum Benefit $2,500

Lifetime Benefit Maximum $2,500

Annual Deductible Individual Family $25.00/$50.00

Preventive Care Routine Exams Type A Preventive

1 in 6 months; unless have a chronic disease, such as diabetes - 1 in 4 months.

Preventive Care Cleanings Prophylaxis Type A Preventive

1 in 6 months; unless have a chronic disease, such as diabetes - 1 in 4 months.

Preventive Care X-Rays Type A Preventive

1 in 60 months; unless have a chronic disease, such as diabetes - in

36 months;.

Preventive Care Fluoride Treatment Type A Preventive Up to 16 yrs once every 12 months

Preventive Care Space Maintainer Type B Diagnostic No age limit or freq limit

Preventive Care Sealants Type B Diagnostic Once per tooth in every 60 months

Minor Restorative Care Amalgam Filings Type B Basic Restorative Once in 24 months

Minor Restorative Care Composite Filings Type B Basic Restorative Once in 24 months

Major Restorative Root Canal Therapy Type B Major Restorative Once in 24 months

Major Restorative Care Periodontics, Scaling and

Root Planning Type B Major Restorative Once in 24 months

Major Restorative Care Crown Bridges Type C Major Restorative Once in 60 months

Major Restorative Care Dentures Type C Major Restorative Once in 60 months

Major Restorative Care Inlays Onlays Type C Major Restorative Once in 60 months

Major Restorative Care Extractions Type C Major Restorative No limit

Major Restorative Oral Surgery Type C Major Restorative No limit

Orthodontia Treatment Type D Orthodontia Yes

Orthodontia Maximum Benefit Orthodontia $3,000.00 maximum annual limitation

Self N/A Self & Spouse N/A Self & Child(ren) N/A Self & Family N/A

Annual Vision Benefit Maximum N/A

Vision Plan Network Coverage N/A

In-Network $5.00 Copay; Once every 12 months

Out-of-Network Up to $30.00

In-Network

$20.00 copay; $200.00 allowance;

20% off after allowance has been used every 12 months. 20% off of second pair of glasses.

Out-of-Network N/A In-Network Single Vision $35 Copay In-Network Bifocal $55 Copay In-Network Trifocal $90 Copay In-Network Lenticular $90 Copay Out-of-Network Single Vision N/A

Dental

Dental & Vision Insurance Benefits Matrix

Eyeglass Lenses

Employee Monthly Premium

Exam with Dilation as Necessary

Eyeglass Frames

Vision

Dental and Vision Insurance Plan

Minimum Requirements

Offeror's Plan (Please fill in how the plan meets or exceeds the minimum requirements)

Dental

Dental & Vision Insurance Benefits Matrix

Out-of-Network Bifocal N/A Out-of-Network Trifocal N/A Out-of-Network Lenticular N/A In-Network Tint (Solid and Gradient) $12 In-Network UV Coating $12 In-Network Standard Scratch-Resistance $12 In-Network Standard Polycarbonate $25 In-Network Standard Anti-Reflective $40

In-Network Standard Progressive (Add-on to

Bifocal) $45

In-Network Other Add-Ons and Service 20% off retail price Out-of-Network Tint (Solid and Gradient) N/A Out-of-Network UV Coating N/A Out-of-Network Standard Scratch-Resistance N/A Out-of-Network Standard Polycarbonate N/A Out-of-Network Standard Anti-Reflective N/A

Out-of-Network Standard Progressive (Add-on to

Bifocal) N/A

Out-of-Network Other Add-Ons and Service N/A In-Network Conventional $150.00 allowance for 12 months In-Network Disposables 20% off retail price; Freq unlimited Out-of-Network Conventional N/A Out-of-Network Disposables N/A

In-Network 20% off retail price or 10% off promotional pricing for 12 months Out-of-Network N/A

In-Network

A 20% discount on remaining balance at Participating Providers beyond plan coverage; the discount does not apply professional services or disposable contact lenses. The plan provides up to a 45% discount on subsequent purchases at an unlimited frequency after the initial benefit has been used.

An additional $15 is added to the lens cost in AK, CA, HI,WA, and OR.

Out-of-Network N/A

Eyeglass Lenses

Eyeglass Lens Options (paid by the member and added to the base price of the lens)

Contact Lenses (allowance covers materials only)

Vision Correction Surgery (LASIK and PRK Vision

Correction Procedures)

Vision

Other Vision Discounts