Jay School Corporation
Anthem Blue Vision-Effective June 1, 2007
Covered Benefits
Vision Examination: once every 12 months
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
Member Benefit from
Anthem Vision Network
No copayment
No copayment
Non-Network
Reimbursement
Up to $55.00
Up to $40
Up to $55
Up to $55
Up to $80
Up to $110
Frames: Maximum allowable amount of
Up to $130
$150 for frames purchased from a Network
provider minus any applicable copayment.
Availability: once every 24 months.
Contact Lenses: Elective-members have a
Elective up to $195
$195 plan allowance minus any applicable
No copaymentcopayment per benefit period toward cosmetic additionally, the plan
contact lenses in lieu of the frames and lens
provides 10% discount on
benefits. The member is responsible for the
disposable lenses and 15%
difference if the contact lenses are greater
on other traditional lesnes
than the plan allowance.
Non-elective-contact lenses prescribed for the
Non-elective up to $195
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
Jay School Corporation-Delta Dental Benefits
Covered Benefits
Payable at
Preventatvie, x-rays, sealants
100%
Basic, Oral surgery ,simple restorative, denture repair
80%
Endodontics, Periodontics, major restorative, Prosthetics, Orthodontics
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