employer group plans - dental select · 2019. 4. 18. · dental select’s vision products are...
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UT2018 VIS.03.9000321 08/18© Copyright Select Benefits Group 2018
Plan Summaries - EyeMed Select Network
Vis 6 Vis 8 Vis 12 Vis 21
In-Network(Member Cost)
Out-of-Network
(Reimbursement)
In-Network(Member Cost)
Out-of-Network
(Reimbursement)
In-Network(Member Cost)
Out-of-Network
(Reimbursement)
In-Network(Member Cost)
Out-of-Network
(Reimbursement)
Exam with Dilation as Necessary $10 Up to $35 $0 Up to $35 $10 Up to $35 $10 Up to $45
Contact lens standard fit & follow-up Up to $40N/A
Up to $40N/A
Up to $40N/A
Up to $40N/A
Contact lens premium fit & follow-up 10% Off retail 10% Off retail 10% Off retail 10% Off retail
Frames:
Any available frame at provider location
$0 Copay; $100 Allowance; 20% Off balance over
$100
Up to $50
$0 Copay; $100 Allowance; 20% Off balance over
$100
Up to $50
$0 Copay; $100 Allowance; 20% Off balance over
$100
Up to $50
$0 Copay; $130 Allowance; 20% Off balance over
$130
Up to $45
Standard Plastic Lenses
Single Vision $10 Up to $25 $0 Up to $25 $10 Up to $25 $25 Up to $40
Bifocal $10 Up to $40 $0 Up to $40 $10 Up to $40 $25 Up to $60
Trifocal $10 Up to $55 $0 Up to $55 $10 Up to $55 $25 Up to $80
Standard Progressive $75 Up to $40 $65 Up to $40 $75 Up to $40 $25 Up to $60
Lens Options
UV Coating $15
N/A
$15
N/A
$15
N/A
$15
N/ATint (Solid and Gradient) $15 $15 $15 $15
Standard Scratch-Resistance $15 $15 $15 $15
Standard Polycarbonate $40 $40 $40 $40
Standard Anti-Reflective $45N/A
$45N/A
$45N/A
$45N/A
Other Add-ons and Services 20% Discount 20% Discount 20% Discount 20% Discount
Contact Lens Materials: Declining balance allowance (may be used on multiple purchases within the same benefit period up to the maximum allowable)
Conventional
$0 Copay; $115 Allowance; 15%
Off balance over $115
Up to $100
$0 Copay; $200 Allowance; 15%
Off balance over $200
Up to $160
$0 Copay; $120 Allowance; 15%
Off balance over $120
Up to $100
$0 Copay; $150 Allowance; 15%
Off balance over $150
Up to $150
Disposables
$0 Copay; $115 Allowance; Member
pays balance over $115
Up to $100
$0 Copay; $200 Allowance; Member
pays balance over $200
Up to $160
$0 Copay; $120Allowance; Member
pays balance over $120
Up to $100
$0 Copay; $150Allowance; Member
pays balance over $150
Up to $150
Medically Necessary$0 Copay; Paid-in-full
Up to $200$0 Copay; Paid-in-full
Up to $200$0 Copay; Paid-in-full
Up to $200$0 Copay; Paid-in-full
Up to $210
Frequency
Examination Once every 12 months Once every 12 months Once every 12 months Once every 12 months
Frame Once every 24 months Once every 12 months Once every 12 months Once every 12 months
Lenses or Contact Lenses 1 Once every 12 months Once every 12 months 2 Once every 12 months 2 Once every 12 months
Note 1: Members also receive a 40% discount off complete pair of prescription eyeglasses purchases and a 15% discount off conventional contact lenses once the funded benefit has been used. Note 2: Benefit available for both Lenses AND Contact Lenses within the same 12 month period.IMPORTANT NOTICE: This information is a brief description of the important features of this insurance plan. It is not an insurance contract. Insurance benefits are underwritten by ACE American Insurance Company. Coverage may not be available in all states or certain terms may be different where required by state law. Chubb NA is the U.S.-based operating division of the Chubb Group of Companies, headed by Chubb Ltd. (NYSE:CB) Insurance products and services are provided by Chubb Insurance underwriting companies and not by the parent company itself.
All plans of insurance are marketed by Dental Select, an insurance agency, and underwritten by ACE American Insurance Company, a member insurer of the Chubb Group of Companies. Chubb NA is the U.S.-based operating division of the Chubb Group of Companies headed by Chubb Ltd. (NYSE: CB) Insurance products and services are provided by Chubb Insurance underwriting companies and not by the parent company itself.
The EyeMed network offers convenient availability of independent providers and leading optical retail providers such as:
Phone: 800-999-9789 dentalselect .com
Insured VisionE M P LO Y E R G R O U P P L A N S
Many locations open 7 days per week, including evenings.
Dental Select’s vision products are provided through EyeMed Vision Care which offers access to more than 98,000 independent practitioners and optical retail providers at more than 25,000 locations nationwide.
In-network laser vision correction is 15% off retail price, and 5% off promotional price.
Order glasses and contact lenses online using in-network benefits through glasses.com and contactsdirect.com.