UPHS_Enrollment_Guide_FINAL

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Print this Guide Human Resources/ Benefits Locations Making Changes During the Year Contact Information Search this Document > Carewise Health Programs Medical Behavioral Health Prescription Drug Vision IBC Davis Vision Premium Plan IBC Davis Vision Standard Plan Vision Benefits of America (VBA) Plan Dental Flexible Spending Accounts (FSAs) Life Insurance AD&D Coverage Disability Legal Notices Welcome What’s New Cost for Coverage Plan Highlights Welcome > Vision > Vision Benefits of Amercia (VBA) Plan Vision Benefits of America (VBA) Plan Vision Benefits of America (VBA) Plan How to Access Care VBA Provider Non-VBA Provider Eye Exam (once per contract Covered at 100% Reimbursed up to $40 year) Standard Lenses (once per Covered at 100% Reimbursed up to $30-$80 contract year) Frames Reimbursed up to $100 Reimbursed up to $30 Medically necessary contact Based on UCR Reimbursed up to $200 lenses (in lieu of eyeglasses) and evaluation and fitting, with prior approval Contact lenses (in lieu of eyeglasses) including standard, specialty and disposable lenses $140 max paid in lieu of exam and glasses $140 max paid in lieu of exam and glasses This chart does not provide a complete description of the plans. For more details, please contact the UPHS Benefits Office at 215-615-2277. Receiving Benefits You must request a claim form before your appointment. The claim is good for 60 days. To obtain a claim form, please contact VBA at 800-432-4966 or log on to their website at www.visionbenefits.com. Along with the claim form, you will also receive a list of participating providers in your area. Please note: There is no vision card associated with this plan.
Print this Guide Human Resources/ Benefits Locations Making Changes During the Year Contact Information Search this Document > Carewise Health Programs Medical Behavioral Health Prescription Drug Vision Dental Penn Faculty Practice Flexible Spending Accounts (FSAs) Life Insurance AD&D Coverage Disability Legal Notices Welcome What’s New Cost for Coverage Plan Highlights Welcome > Dental Dental PENN Faculty Practice (PFP)* Delta Dental* Aetna DMO How to Access Care Go to any PFP network provider Go to any dental care provider (benefits may be greater with a Delta Care must be coordinated by your Primary Care dentist Dental provider) Referrals Needed No No Yes Annual Deductible $50/person, $150/family (on basic, major and ortho) $50/person, $150/family (on basic, major and None Coinsurance • Preventive • Basic • Major • Orthodontic Plan pays: • 100% • 80% • 50% • 50% up to $2,000 lifetime orthodontic maximum (for dependent children to age 19 only) ortho) Plan pays: • 100% of Delta’s allowance • 80% of Delta’s allowance • 50% of Delta’s allowance • 50% of Delta’s allowance up to $1,500 lifetime orthodontic maximum (for dependent children to age 19 only) Plan pays: • 100% • 100% • 50% • 50% (for adults and dependent children); no lifetime orthodontic maximum Annual Maximum $3,000/person Premier – $1,500/person None Benefit PPO – $2,000/person *The Dental Plan contains a provision that coordinates the benefits it pays on behalf of an individual with payments that may be made under other plans covering the individual, so that the total benefits available will not exceed 100% of the allowable expenses. Please see your Summary Plan Description for more information. This chart does not provide a complete description of the plans. For more details, please contact the UPHS Benefits Office at 215-615-2277.
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