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2016-2017 Page 6
Lessie Bates
2016-2017 Annual Enrollment
Metlife Dental
Type of Coverage
Cost Per Payroll
Deduction
Employee
$7.65
Employee & Spouse
$16.84
Employee & Child(ren)
$19.93
Employee & Family
$32.58
Benefits
PPO Network
Out of
Network
Deductible
Individual
Family
$50
$150
$50
$150
Coinsurance
Diagnostic/Preventive
- Cleanings
Basic Services
- Periodontics
- Endodontics
Major Services
Orthodontia
100% (no ded.)
80%
80%
80%
50%
50%
80%
80%
80%
80%
50%
50%
Annual Maximum
Orthodontia Maximum
$1,500/person per year
$2,000/person per year
Metlife Life Insurance
Lessie Bates provides this benefit through Metlife Insurance at no cost to you. This protection provides
$10,000
of life
insurance for each employee. Each benefit amount also carries an equal benefit of accidental death and dismember-
ment coverage. Please refer to your certificate of coverage for the age reduction schedule if applicable.
If you have not already done so, now is a great time to ensure that we has the most up to date beneficiary information
on file for you. Please let Human Resources know if you need to make a change to this information.
VSPVision Insurance
Benefit/Service
In Network
Out of Network
Allowance
Examination
Co-pay
$20 Co-pay
Up to $50
Frequency of
Service:
Exam
Lenses
Frames
Every 12 months
Every 24 months
Every 24 months
Standard Lenses
Single
Bifocal
Progressive
Trifocal
$20 Co-pay, then
100%
100%
100%
100%
Reimbursement
$50
$75
$75
$100
Frames
$120 retail
allowance
Reimbursement
$70
Contact Lenses
Medically Necessary
Cosmetic
100%
Covered up to $120
Reimbursement
Up to $210 retail
Up to $105 retail
Type of Coverage
Per Pay Period
Deduction
Employee
$1.61
Employee & Spouse
$2.58
Employee & Child(ren)
$2.63
Employee & Family
$4.24