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DENTAL & VISION
Voluntary Dental
Aetna PPO
Services
In-Network
Out-of-Network
Deductible
$50 Individual
$150 Family
Diagnostic & Preventative Services
100%
100%
Basic Services
80%
80%
Major Services
50%
50%
Annual Maximum
$1,000
$1,000
Lifetime Orthodontia Maximum
$1,000
$1,000
VOLUNTARY BENEFITS
Voluntary Vision
Services
In-Network
Out-of-Network
Examinations
$15
Up to $40
Lenses
Single Vision
Bifocal
Trifocal
$15 copay
$15 copay
$15 copay
Up to $35
Up to $50
Up to $75
Frames
Up to $150
Up to $65
Contact Lenses
Up to $150
Up to $150
Vision
The vision plan allows you and your dependents to receive a routine eye examination, traditional
lenses or contact lenses once every rolling 12 months, frames are once every rolling 24 months. You
and your dependents may receive care from a participating or non-participating provider. However, if
you use a non-participating provider you will incur higher out-of-pocket expenses.