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Benefit

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Diamond

Platinum
Vision Benefits
Annual Deductible None None $20 per person
Eye Exam As often as you wish
$36 co-pay 		As often as you wish
$36 co-pay 		Every 12 months
100% covered up to plan allowance
Lenses As often as you wish + copay

As often as you wish
+ co-pay

Every 12 months
100% covered
Frames As often as you wish
25% discount 		As often as you wish
25% discount 		Every 24 months
100% covered up to plan allownace
Cosmetic Contact Lenses

As often as you wish
+ co-pay

As often as you wish
+ co-pay

Every 12 months
in addition to the basic benefit or, if desired, in lieu of the basic benefit, $100 applies to the doctor's usual and customary package fee which includes eye examination, fitting and contact lenses.
Medically Necessary Contact Lenses Available as custom contact lenses at 20% off. Available as custom contact lenses at 20% off. Every 24 months
A $250 benefit including a $75 deductible
Dental Benefits
Office Visit $5 co-pay No Charge No Charge
Dental Exam No Charge No Charge No Charge
X-rays No Charge No Charge No Charge
Cleaning No Charge No Charge No Charge
Floride Treatment No Charge
Up to age 14 		No Charge
Up to age 14 		No Charge
Up to age 14
1 or 2 Surface Filling $10 to $15
co-pay 		$2 to $3 co-pay $2 to $3 co-pay
Bi Rooted Canal $150 without final restoration $90 without final restoration $90 without final restoration
Orthodontia $1,975 Adult upper and lower $1,695 Adult upper and lower $1,695 Adult upper and lower
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