Morgan-White Dental/Vision

Transcription

1 organ-white Dental/Vision Prepared or To or have questions answered call You may also return apps to or by fax to Date Prepared: 11/15/2011

2 organ-white Dental/Vision No Deductible No Waiting Periods National PPO Network 1 office visit exam Out of Network claims paid up to the 85th percentile of UCR $1,000 per person, calendar year maximum Diagnostic and Preventative paid at 90% (One office visit, exam, one set of bitewing x-rays, and cleaning every six months) illings and Simple Extractions paid at 80% (One, two, three and four surface amalgams, and simple extractions) Cleaning every six months Plus limited inor Restorative or each covered individual who uses less than $500 of their benefits in a plan year, $250 will be added to the next plan year s annual maximum. If all the claims submitted are thru an authorized PPO provider you will receive an additional $100 on next year s annual maximum. The annual max may be increased up to an additional $1,000. Covered Code* Procedure 2 In-Out Network Co-insurance D0120 EXA -Periodic Oral Evaluation 90% D0140 Limited Oral Evaluation 90% D0150 Comprehensive Oral Evaluation 90% D0270 XRAY-Bitewings - single film 90% D0272 XRAY-Bitewings - two films 90% D0274 XRAY-Bitewings - four films 90% D1110 Prophylaxis - Adult 90% D1120 Prophylaxis - Child 90% D2140 Amalgam - 1 surface, primary or permanent 80% D2150 Amalgam - 2 surfaces, primary or permanent 80% D2160 Amalgam - 3 surfaces, primary or permanent 80% D2161 Amalgam - 4 or more surfaces, primary or permanent 80% D7110 Extraction single tooth 80% D7111 Single Extraction- coronal remnants deciduous tooth 80% *Only the procedure codes listed on this page will be covered under this plan. Dental products are underwritten by UnitedHealthCare Insurance Company, Hartford, CT (except in New York), or United HealthCare Insurance Company of New York, Hauppauge, NY (New York only). Not affiliated with UnitedHealthcare edical.

3 organ-white Dental/Vision Your Vision is Our ocus When you take a look at our vision plan, you ll see for yourself that the Basic Vision Plan offers one of the most comprehensive prevention, examination, and prescription programs available. We focus on value, quality, and affordability, and offer a large network of credentialed private practice and retail chain providers. The Basic Vision Plan includes a routine vision exam (including refraction), as well as preferred pricing on eyeglasses and contact lenses. Routine vision exam (including refraction) paid in-full after copay. Once every 12 months Preferred Pricing offered on frames, lenses, and lens options at private practice providers, and discounts at retail chains No limit on purchases of eyeglasses and contacts at preferred pricing A network of credentialed private practice and retail chain providers Access to discounts on laser vision correction through a nationwide Network of more than 300 laser vision correction specialists 24-hour access to benefit information through and our toll-free Interactive Voice Response (IVR) line at No claim forms Description You Pay 1 Vision Exam Once every 12 months Paid-in-full after $20 copay rames 2 At private practice providers At retail chain providers Standard Lenses 3 Contact Lenses Covered-in-full frames Quality Collection frame Elite Collection frame Non-Collection frames embers receive a discount Single vision lenses Bifocal Lenses Trifocal Lenses itting, follow-up, and materials Contact lenses (non-disposable) Contact lenses (disposable) Access to mail-order contact lenses Preferred pricing: $60 $85 15% Discount Discount Preferred pricing: $45 $65 $95 ember pays full provider-billed charges Refractive Eye Surgery embers receive access to discounted refractive eye surgery procedures 1.Preferred pricing is only available at network provider locations. Please consult you vision care provider for preferred pricing on additional lens styles (i.e. progressive lenses), materials, and options (i.e. coatings, tints, etc.). or more information, call member services or visit 2.embers receive preferred pricing on frames at network private practice providers, and a discount at network retail chains. Discounts are off of network providers billed charges; the discount is 15% for all frames not included in the covered-in-full selection. 3.Standard lenses: non-aspheric, glass/plastic (CR39), clear, all powers, all sizes, standard scratch-resistant coating. Lower prices on Standard lenses and contacts will apply at some retail locations. 3 Spectera, Inc. administers vision benefits underwritten by the following entities: United HealthCare Insurance Company, United HealthCare Insurance Company of New York, Unimerica Insurance Co., Inc., and American General Assurance Company

4 organ-white Dental/Vision Weekly Rates Employee cost per pay period BASIC PLAN ember $4.15 ember + 1 $7.62 amily $10.62 or ore Information Contact Lucia da Silveira President LDS Benefits 1049 Camino Del ar Suite 1 Del ar, CA Bus (858) 793-LdS1 (5371) ax (858) 793-LdS2 (5372) Alt. (858) 793-LdS3 (5373) Pan-American Life and organ-white are not affiliated. 4

5 Dental ment orm Group Dental Coverage Provided by United HealthCare Insurance Company SOCIAL SECURITY NUBER EPLOYEE ID NUBER (if different than SSN) Waiver DATE : / / LAST NAE IRST NAE I ADDRESS CITY STATE ZIP TELEPHONE NUBER HOE ( ) WORK ( ) APPLICANTS DATE O BIRTH EPLOYER OR GROUP NAE ale Single emale arried Dental ment Effective Date: / / TRADITIONAL PLAN Benchmark Open Choice Incentive Opportunity PACKAGE PLAN Plan A Plan B Plan C IEDIATE COVERAGE PLAN PLAN COVERAGE Employee Employee + One Employee + Spouse Employee + Child(ren) amily Vision ment - Add Optional WG Vision Coverage PLAN COVERAGE Employee Employee + One amily Add Vision Coverage irst Name Initial Last Name (if different) INORATION OR DEPENDENT COVERAGE Spouse & Unmarried Dependent Children Only (Include Date of Birth) Date of Birth (o/day/yr) Wife Relationship Husband If Child is over 19, please indicate status and school *or court ordered dependent, legal documentation must be attached. Please see employer representative for more information about the qualifications for full-time student status. If dependent does not reside with eligible employee, please provide address on separate sheet. OR INTERNAL USE ONLY EPLOYER or GROUP AUTHORIZATION EECTIVE DATE TYPE O COVERAGE SIGNATURE I hereby understand that any coverage is limited by the benefits and exclusions of the Group Dental Agreement INIU ENROLLENT IS OR ONE YEAR Unimerica Dental Indemnity Plan is underwritten by United HealthCare Insurance Company, Hartford, Connecticut (except in New York), United HealthCare Insurance Company of New York; Hauppauge, New York (New York Only. UHC DenEEApp (10/03)