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DENTAL PLAN FEATURES |
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VISION CARE BENEFITS
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BENEFIT
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Plan A
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Plan B
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BENEFIT |
Plan A |
Plan B |
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| CALENDAR YEAR MAXIMUM* |
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M.D. Comprehensive
Examination |
$75.00
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$37.50 |
| Per Insured Person |
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O.D. Comprehensive
Examination |
$60.00
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$60.00
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| All Benefits |
$1,500 |
$1,000 |
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M.D. Follow-up Examination
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$60.00
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$60.00
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| Class IV Orthodontia |
$500 |
N/A |
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O.D. Follow-up
Examination |
$60.00
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$60.00
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| CALENDAR YEAR DEDUCTIBLE |
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A Comprehensive Examination is limited to one exam per 24 month period. A follow-up Examination is limited to one exam per 12 month period.
* Benefits for dental and vision will be combined and not to exceed the Calendar year maximum under the plan selected. |
| Per Insured Person |
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| Dental and Orthodontia |
$50
(X3) |
$50
(X3) |
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| Class 1 Preventative |
Waived |
Waived |
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| PRETREATMENT REVIEW |
$300 |
$300 |
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| COVERED BENEFITS |
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VISION LENS(ES) AND FRAMES
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| Class I Preventative |
100% |
100% |
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Bifocal Lens |
$35.00 |
$17.50 |
| Class II Basic |
80% |
50% |
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Trifocal Lens |
$45.00 |
$22.50 |
| Class III Major |
50% |
50% |
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Lenticular Lens (single) |
$45.00 |
$22.50 |
| Class IV Orthodontia |
50% |
N/A |
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Lenticular Lens (multiple) |
$56.00 |
$28.25 |
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Contact Lens |
$25.00 |
$21.50 |
| MINIMUM GROUP SIZE |
10 |
2 |
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Frame |
$50.00 |
$25.00 |
| EMPLOYER CONTRIBUTION |
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Lens(es) and frames are limited to one set per 24 month period. Contact lens(es) are limited to one set per 24 month period and are in lieu of all other eyewear benefits. |
| Employee Contribution |
75% |
75% |
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| PARTICIPATION REQUIREMENTS |
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| Employee |
75%
(5+) |
100%(2-4) |
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75%
(5+) |
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| Dependent |
50% |
50% |
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Usual, Customary and Reasonable |
Yes |
Yes |
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ELIGIBILITY GUIDELINES
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Firms: Eligible firms are sole proprietorships, partnerships or corporations with at least two full time employees, including active, fulltime owners or partners.
Insureds: An Insured is an Employee of the Eligible Class for Personal Insurance, who has qualified for insurance by completing the waiting period for the firm, if any; and for whom the insurance has become effective. For the purpose of Dental Expense Benefit, Vision Benefit and Orthodontic Expense Benefit, if included, Insured also means any eligible dependent which the Insured has elected to enroll under the Policy.
Dependents: Eligible dependents include the insured spouse and unmarried children prior to their 19th birthday who do not work for the firm. In addition, unmarried children from their 19th birthday to the day before their 24th birthday are eligible if they are fulltime students attending an accredited educational institution and primarily dependant upon the employee for support and maintenance. Also included is each unmarried child age 9 who becomes totally disabled while insured while a fulltime student at an accredited school or college and who is primarily dependent on the Insured for support and maintenance. Coverage for such child will not cease if proof of dependency and disability is given 31 days after the Company requests it. Dependent means all the people who are insured as the dependents of any one Insured.
Ineligible Industries: Provident American reserves the right to reject any business or industry that does not, in our opinion, represent a sound underwriting risk.
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TAKEOVER BENEFITS
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Takeover means that you and your employees are given credit for waiting periods for like coverage accumulated under your existing plan. This applies to groups with 5 or more eligible Insureds.
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Please read the Exclusions and Limitations
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