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Employee Benefit Guide 2012 - City of Oklahoma City

Employee Benefit Guide 2012 - City of Oklahoma City

Dental Plan

Dental Plan Employee Information This is a general summary of your benefit design. Please refer to your dental benefit booklet for other details and for limitations and exclusions. Eligibility The following eligibility provisions apply: • Dependent children are covered to age 26. Disabled dependent children can be covered beyond age 26. • Retirees are eligible for coverage. Pre-Existing Condition A pre-existing condition exclusion will apply to expenses involving the replacement of teeth that were missing prior to the effective date of the dental contract. This exclusion will not apply to: • Any participant who becomes effective on the dental contract date who was covered under a previous group dental care contract by the Employer. • Any participant who has been continuously covered for 24 months under a group dental care contract with BlueCross BlueShield of Oklahoma, which included prosthetic benefits. BlueCross BlueShield of Oklahoma Limitations When the course of treatment will be in excess of $300, a predetermination request should be submitted to BlueCross BlueShield of Oklahoma in advance of treatment. • Low Plan Option: When seeing a Non-Contracting Dentist: Your out–of-pocket cost will be greater because Non-Contracting Dentists have not entered into a contract with BlueCross BlueShield of Oklahoma to accept any Allowable Amount determination as payment in full for Eligible Dental Expenses. Claims will be reimbursed at the Maximum Allowable Charge (MAC). You are required to file claim forms. You are balanced billed for costs exceeding the BlueCross BlueShield of Oklahoma Allowable Amount. • High Plan Option: When seeing a Non-Contracting Dentist: Your out–of-pocket cost will be greater because Non-Contracting Dentists have not entered into a contract with BlueCross BlueShield of Oklahoma to accept any Allowable Amount determination as payment in full for Eligible Dental Expenses. Claims will be reimbursed at the 90th percentile. You are required to file claim forms. You are balanced billed for costs exceeding the BlueCross BlueShield of Oklahoma Allowable Amount. Please note that our dental plan is a “freestanding” product and can be purchased separately from the health product, i.e., an employee can have only himself covered for health, but have dental for the family and vice versa. Find out what Dentists are on your dental plan. This information may be found using the City’s intranet. Type in http:// InsideOKC/Employee/Benefits, click on Links, then click Dental Plan. 24

Vision Care Plan VSP Your VSP Vision Benefits Summary Why enroll in a VSP® Vision Care plan? We’ll help keep you and your eyes healthy. Plus, you’ll get a great value on your eyecare and eyewear. You’ll Like What You See with VSP Value and Savings You’ll get great benefits on your exam and eyewear at an affordable price. Personalized Care You’ll get quality care that focuses on your eyes and overall wellness with a WellVision Exam® from a VSP doctor. They’ll look for vision problems and signs of other health conditions. When you see a VSP doctor, you’ll get the most out of your benefit and have lower out-of-pocket costs. Plus, you’ll be 100% happy with your eyecare and eyewear from a VSP doctor or we’ll make it right. Eyewear Choose the eyewear that’s right for you and your budget. From classic styles to the latest designer fashions, you’ll find hundreds of options for you and your family. Choice of Providers With open access to see any eyecare provider, you can see the one who’s right for you. Choose a VSP doctor or any other provider. To find a VSP doctor, visit vsp.com or call 800-877-7195. Enroll today. You’ll be glad you did. Once your plan is effective, register on vsp.com to view a complete description of your benefits. To use your vision coverage, simply tell your eyecare provider that you have VSP. No ID card is necessary. Contact us: vsp.com 1-800-877-7195 VSP guarantees service from VSP doctors only. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Doctor Network ........................................................ VSP Choice Your Coverage with a VSP Doctor WellVision Exam® focuses on your eye health and overall wellness • $10 copay .............................................................................. every calendar year Prescription Glasses • $25 copay Lenses ............................................................................................. every calendar year • Single vision, lined bifocal, and lined trifocal lenses • Polycarbonate lenses for dependent children Frame .............................................................................................. every calendar year • $130 allowance for a wide selection of frames • 20% off the amount over your allowance OR Contact Lens Care • No copay ............................................................................. every calendar year $130 allowance for contacts and the contact lens exam (fitting and evaluation). Current soft contact lens wearers may qualify for a special program that includes a contact lens exam and initial supply of replacement lenses. Extra Discounts and Savings Glasses and Sunglasses • Average 20-25% savings on all non-covered lens options • 20% off additional glasses and sunglasses, including lens options, from any VSP doctor within 12 months of your last WellVision Exam Contacts • 15% off cost of contact lens exam (fitting and evaluation) Laser Vision Correction • Average 15% off the regular price or 5% off the promotional price. Discounts only available from contracted facilities. Your Coverage with Other Providers Visit vsp.com for details, if you plan to see a provider other than a VSP doctor. You have 6 months to submit a claim to VSP for reimbursement. Visit vsp.com for details. Exam ............................................................................................................... Up to $45 Single vision lenses .................................................................................. Up to $30 Lined bifocal lenses ................................................................................. Up to $50 Lined trifocal lenses ................................................................................. Up to $65 Frame ............................................................................................................. Up to $70 Contacts ....................................................................................................... Up to $105 25

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