Aetna Dental / VSP Vision

YOU CANNOT ENROLL IN VISION ONLY OR DENTAL ONLY. THE DENTAL AND VISION PLANS CAN ONLY BE PURCHASED AS A PACKAGE AND YOU MUST ENROLL IN BOTH PLANS WITH THE SAME ENROLLMENT.

FOR EXAMPLE: IF YOU CHOOSE HUSBAND & WIFE FOR DENTAL, THEN YOU MUST ENROLL IN VISION AS HUSBAND & WIFE.

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AETNA DENTAL

Dental is offered through Aetna Insurance. There is a choice of two plans, PPO where you have free choice as to dentist, and DMO (like HMO) where you must select from a list of participating providers. NOTE: There is no waiting period under this plan.

Orthodontic Services are EXCLUDED from the plan.

Benefit Comparison

Dental Summary (Voluntary)
Aetna Dual Option
PPO DMO (HMO)
In-Network Out-Network
Preventive Services 80% Benefit 80% Benefit 100% Benefit
Basic Services 80% Benefit 80% Benefit Scheduled
Major Services 50% Benefit 50% Benefit Scheduled
Orthodontic Services NONE NONE NONE
Annual Deductible $50 NONE
Annual Maximum $1000 NONE

Rates

Rates Effective 1/1/2016 to 12/31/2016

Dental Rates (Voluntary)
Aetna Dual Option
PPO DMO (HMO)
Single $58.16 $21.42
Husband & Wife $120.12 $42.45
Parent & Child(ren) $113.94 $44.71
Family $177.00 $65.73

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VISION SERVICE PLAN (Vision)

The VSP Vision Plan utilizes participating and non-participating doctors. The Plan has a $10 copay and 100% reimbursement for most in-network services. There is an option to utilize non-network doctors, however reimbursement is based on a fee schedule.

BENEFITS

Examination
Once every 12 months
Lenses Once every 24 months
Frame Once every 24 months

COPAYMENT: $10.00

Services from a
VSP Participating
Provider (Note 1)
Services from a
Non-Participating
Provider
Examination Paid-in-Full up to $45.00
Single Vision Lenses Paid-in-Full up to $45.00
Bifocal Lenses Paid-in-Full up to $65.00
Trifocal Lenses Paid-in-Full up to $85.00
Lenticular Lenses Paid-in-Full up to
$125.00
Frame A wide selection of attractive frames are covered in full. (Note 2) up to $47.00
Contact Lenses –
Instead of glasses (Note 3)
Medically Necessary Paid-in-Full up to $210.00
Elective up to $130.00 up to $105.00
Low
Vision –
Professional services for severe visual problems not
corrected with regular lenses, including:
Supplemental Testing
(includes evaluation, diagnosis and prescription of vision aids where
indicated)
Covered-in-Full up to $125.00
Supplemental
Aids
75% of cost 75% of cost
Maximum allowable for all Low Vision benefits of
$1000.00 every two (2) years.

When an examination and/or materials are received from a VSP participating provider, the patient will have no out-of-pocket expense other than the copayment, unless optional lenses are selected. Optional items include, but are not limited to, oversize lenses (61mm or larger), coated lenses, np-line multifocal lenses, treatments for cosmetic reasons, or a frame that exceeds the plan allowance

VSP’s frame benefit fully covers over half of the 42,000 frames currently available. Due to this large selection and the fact that buying habits and tastes differ from one region to the next, frame inventories may vary from office to office. When deciding on a frame, members should ask their doctors which ones are covered in full.

When receiving services for elective contact lenses, the standard eye examination is covered in full. The stated allowance is provided toward the contact lense evaluation, fitting costs, and the lenses. Any costs exceeding this allowance are the patient’s responsibility.

MONTHLY PREMIUMS for VISION

Coverage Monthly Premium
Single $8.41
Employee & Spouse $13.45
Parent & Child(ren) $13.73
Family $22.13

Rates

Rates Effective 5/1/2014 to 4/30/16

Rate and Comparison charts on this website are provided for informational purposes ONLY and are not to be considered as binding. Not all areas or plans are listed. While every effort is made to maintain the accuracy of this information, you should contact The OSSA Group to confirm rates and coverages available in your area.

If you are a current Block Staffing employee and would like to receive an information pack outlining the specific plans and rates available to you, contact Joe Marini at The OSSA Group, or call 1–800–582–8203 and he will get one in the mail to you.

Aetna Enrollment

Vision and Dental Benefits Summary