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DENTALCOVERAGE AvailableinCalifornia&Hawaii Dentalcoverageprovidesperiodicpreventivecare,andifthere’saproblem,helpswiththecostofdentalwork.TofindanInͲnetworkprovider withMeritain(Aetna)gotowww.aetna.com/docfind/custom/mymeritainandsearchthe“AetnaDentalAdministrators”network.
MERITAIN Network
InͲNetwork
OutͲofͲNetwork* $25/$75
AnnualDeductible(Individual/Family) PreventiveCare
PlanPays100%
PlanPays100%(UCR)
PlanPays80%afterdeductible
PlanPays80%afterdeductible(UCR)
PlanPays50%
PlanPays50%(UCR)
(Exams,Cleanings,XͲrays,etc.) BasicServices (FillingsExtractions,etc.) MajorServices (Crowns,Bridges,Dentures,etc.) $1,250
AnnualMaximum
Notcovered
Orthodontia
*Note:IfyouvisitanOutͲofͲNetworkprovider,youareresponsibleforanychargesaboveusual,customaryandreasonable(UCR)limits.Also referredtoas"balancebilling".
VISIONCOVERAGE Youwillreceivethebestcarefromanetworkdoctor,howeverthedecisionisyoursͲͲͲchooseanetworkdoctor,aparticipatingretailchain,or anyoutͲofͲnetworkprovider.Tofindaneyedoctorwho’srightforyou,visitwww.vsp.com. VSPChoicePPOPlan
VisionServiceProviders Network
InͲNetwork
OutͲofͲNetwork
VisionExamͲEvery12months
$10copay
$45allowanceafter$10copay
EyeglassLensesͲEvery12months
$25copay
$30Ͳ100allowanceafter$25copay.Variesby lenstype.
Coveredupto$150allowanceafter$25copay $80allowanceforframesatCostco 20%savingsonamountoverallowance
$75allowanceafter$25copay
ContactLens(InLieuofGlasses)ͲEvery12 months
Coveredupto$150allowance
Coveredupto$105allowance
ContactLensedExam
Coveredupto$60allowance
Coveredupto$45allowance
FramesͲEvery12months
ContractedprovidersagreetobillVSPdirectlyandtoacceptanegotiatedfeeaspaymentinfull.IfyouuseanonͲVSPprovider,youwillneedto submitaclaimtoVSPandyouwillbereimburseduptothescheduledamounts.