TABLE OF CONTENTS DESCRIPTION. Website and Contacts 2
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1 TABLE OF CONTENTS DESCRIPTION PAGE Website and Contacts 2 Health Insurance Health Insurance Rates 4 Health Insurance Calculations 5 Benefit Overview 6 Vantage 2000/25/60 Benefit Details 7-8 Dental Insurance Dental & Vision Rates 10 Dental Benefit Details 11 Vision Benefit Details 12
2 WEBSITE AND CONTACTS To view this booklet as well as claim forms and provider lookups, go to We have also created a new ticket system, allowing you to create a support ticket on our website. This system can be used for things like claims problems, provider directories, address changes, etc. Once the ticket is created, you will automatically be assigned a ticket number and login credentials to view the status of your ticket 24 hours a day. This system is SSL secured and allows for documents to be scanned and uploaded. To create a support ticket, go to CONTACTS National Headquarters PO Box 1472 Virginia Beach, VA Ph F President W. Brandon Beavers Cell: Office: Extension 110 brandon@bladebc.com Director of Benefits Amy Thompson Direct: Office: Extension 112 amy@bladebc.com For a complete list of Limitations and Exclusions, as well as the ACA Mandated Summary of Coverage and Benefits go to: Page 2 Emergency Restoration Services Employee Benefits
3 HEALTH INSURANCE HEALTH BENEFIT COMPARISON HEALTH BENEFIT DETAILS
4 HEALTH INSURANCE RATES Page 4 Employee Weekly Rates Dependent Weekly Rates Emergency Restoration Services Employee Benefits
5 CALCULATING YOUR PAYROLL DEDUCTION Each person in the family has their own rate. Due to ACA, you have to find each person s age in your family and add them up to find your total weekly rate. Please use the calculator below as a guide: Employee Rate: Spouse Rate: Child 1 Rate: Child 2 Rate: Child 3 Rate: Total Weekly Rate: = **All rates shown are weekly. Optima charges for the first three children ONLY. Any additional children have no cost. If your deduction is $0 or less, there will be no deduction from payroll. Page 5 Emergency Restoration Services Employee Benefits
6 HEALTH BENEFIT OVERVIEW BENEFITS AND FEATURES For a complete list of Limitations and Exclusions, as well as the ACA Mandated Summary of Coverage and Benefits go to: Emergency Restoration Services Employee Benefits Page 6
7 OPTIMA VANTAGE 2000/25/70 BENEFIT DETAILS Page 7 Emergency Restoration Services Employee Benefits
8 OPTIMA VANTAGE 2000/25/70 BENEFIT DETAILS Emergency Restoration Services Employee Benefits Page 8
9 DENTAL & VISION INSURANCE DENTAL & VISION RATES DENTAL & VISION BENEFIT PLAN
10 DENTAL & VISION INSURANCE RATES DENTAL & VISION RATES If you elect dental, vision is included for the same price Effective November 1, 2015 Weekly Payroll Deduction United Concordia Employee Only $8.07 Employee + Spouse $14.93 Employee + Child(ren) $14.38 Family $23.37 Page 10 Emergency Restoration Services Employee Benefits
11 DENTAL PPO BENEFIT DETAIL Emergency Restoration Services Employee Benefits Page 11
12 VISION BENEFIT DETAILS UCVision Plan II UCVision Benefits Plan II Details In-Network Coverage Eye Examination Eye Exam (with dilation when professionally indicated) Frames Collection Non-Collection Spectacle Lenses Clear glass or plastic lenses in single vision, bifocal, trifocal or lenticular prescription Spectacle Lens Options Oversize Lenses Tinting of Plastic Lenses Scratch-Resistant Coating Frequency (once every) Member Pays 12 months $0 24 months Fashion: $0 Designer: $0 Premier: $25 $0 ($130 allowance, 20% discount on remaining balance*) 12 months $15 $30 Polycarbonate Lenses ($0 for dependent children, monocular patients and patients with prescriptions +/ diopters or greater) Ultraviolet Coating $12 Anti-Reflective Coating (Standard / Premium / Ultra) $35 / $48 / $60 12 months Progressive Lenses (Standard / Premium) $50 / $90 Intermediate-Vision Lenses $30 Blended-Segment Lenses $20 High-Index Lenses $55 Polarized Lenses $75 Photochromic Glass Lenses $20 Plastic Photosensitive Lenses $65 Scratch Protection Plan (Single Vision / Multifocal) $20 / $40 Contact Lenses (in lieu of eyeglasses) Collection: $15 Contact Lens Evaluation, Fitting & Follow-up care Non-Collection: Member receives 15% discount 12 months Collection: $0 (up to 8 boxes) Contact Lenses Non-Collection: $0 ($130 allowance, 15% discount on remaining balance*) Value-Added Features One-Year Eyeglass Breakage Warranty Lens123 Membership $0 Laser Vision Correction Member receives up to 25% discount on providerr s usual fee, or 5% discount on advertised specials, whichever is lower Out-of-Network Coverage Frequency (once every) Member Reimbursement Eye Exam 12 months up to $45 Frames 24 months up to $50 Single Vision up to $40 Bifocal up to $60 Spectacle Lenses Trifocal up to $80 12 months Lenticular up to $90 Non-Collection Contact Lenses (includes evaluation, fitting & follow-up care) up to $120 Representative listing of covered services certificate of coverage provides a detailed description of benefits. UCVision benefits administered by Davis Vision, Inc. Discounts and value-added features not underwritten by United Concordia Dental. *Discount does not apply to services or materials from a Walmart or Sam s Club vision center. Contact your United Concordia Dental representative for more information. UnitedConcordia.com $0 Page 12 Emergency Restoration Services Employee Benefits
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