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Plan Description
VisionRx > Vision PPO
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Note: This page contains a brief summary of coverage. It does not
state all provisions and limitations of the plan. The terms and provisions of
each plan, as outlined in the plan document, will determine coverage and
eligibility.
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Broker Name:
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VisionRx
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Policy Number:
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34512435
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Original Plan Effective Date:
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12/11/2002
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Rate Guarantee Expiration Date:
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12/11/2002
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Plan Anniversary Date:
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12/11/2202
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Division:
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All Divisions
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Location:
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California
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Employee Classes:
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Full Time
Manager
Officer
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In Network
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Out of Network
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General Plan Information
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Examination
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$15 copay
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$15 copay
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Materials
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$15 copay
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$15 copay
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Benefit Frequency
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Examination
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12 months
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12 months
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Lenses
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12 months
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12 months
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Frames
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24 months
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12 months
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Contacts (in lieu of Lenses and Frames)
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12 months
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12 months
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Covered Services
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Single Vision Lens
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$10 copay
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$10 copay
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Bifocal Lens
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$10 copay
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$15 copay
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Trifocal Lens
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$10 copay
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$15 copay
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Contact Lenses
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- Medically Necessary
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$10 copay
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$15 copay
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- Elective
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$10 copay
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$15 copay
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- Frames
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$10 copay
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$15 copay
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Lens Options
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UV Coating
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Not Covered
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Not Covered
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Other Services
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Corrective Vision Services (e.g. Laser Surgery)
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Not Covered
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Not Covered
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Second Pair of Glasses
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Not Covered
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Not Covered
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Waiting Period Information
Eligible employees are eligible as of the 1st of the month following the employee's hire date.
Termination of Coverage Information
When a plan participant is terminated from the company, the plan coverage ends on the last day of the month following the employee's termination date.
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(per month)
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Employee Cost
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Company Cost
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Total
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Employee
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$0
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$15.43
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$15.43
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Employee + Spouse
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$5.23
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$49.32
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$54.55
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Employee + Child(ren)
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$32.01
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$91.02
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$123.03
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Family
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$65.23
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$154.23
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$219.46
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Delta Dental Plan of Michigan
Member Services
John Carpet
P.O. Box 173
Detroit, MI
80217
(303) 741-9300
Fax (303) 225-3453
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