Jay School Corporation

Jay School Corporation

Anthem Blue Vision-Effective June 1, 2007

Covered Benefits / Member Benefit from
Anthem Vision Network / Non-Network
Reimbursement
Vision Examination: once every 12 months / No copayment / Up to $55.00
Standard lenses: Choice of glass or plastic lenses in single vision, bifocal, or trifocal lenses up to 55 mm; and all ranges of prescriptions.
Single vision lenses(pair)
Bifocal lenses(pair)
Progressive lenses(pair)
Maximum allowable amount equal to bifocal amt
Trifocal lenses (pair)
Lenticular (pair)
Availability: once every 12 months
Frames: Maximum allowable amount of $150 for frames purchased from a Network provider minus any applicable copayment.
Availability: once every 24 months. / No copayment / Up to $40
Up to $55
Up to $55
Up to $80
Up to $110
Up to $130
Contact Lenses: Elective-members have a $195 plan allowance minus any applicable copayment per benefit period toward cosmetic contact lenses in lieu of the frames and lens benefits. The member is responsible for the difference if the contact lenses are greater than the plan allowance.
Non-elective-contact lenses prescribed for the following conditions: following cataract surgery, extreme visual acuity or other functional problems not correctable by spectacle lenses. Covered up to $250 in Network.
Contact lens fitting fee: Any remaining amount from the contact lens allowance can be applied toward the fitting as long as it occurs on the same day as the dispensing of the contacts.
Availability: once every 12 months / No copayment-additionally, the plan provides 10% discount on disposable lenses and 15% on other traditional lesnes / Elective up to $195
Non-elective up to $195

Jay School Corporation-Delta Dental Benefits

Covered Benefits / Payable at
Preventatvie, x-rays, sealants
Basic, Oral surgery ,simple restorative, denture repair
Endodontics, Periodontics, major restorative, Prosthetics, Orthodontics / 100%
80%
50%
Maximum benefit: $500 per person per year
Bitewings: payable twice per calendar year
Crowns: once per tooth in 60 months
Full mouth x-rays: once per 36 months
Sealants: one per tooth per lifetime
Orthodontics: covered to age 19
Exams, cleanings, fluorides: twice in a calendar year
Root planning and scaling: once per quadrant in 24 months, occlusal guards are payable once in a lifetime
Bridges and dentures: benefit with a 60 month replacement limit