Out of Network. Covered for Medical Base Plan with $600 deductible and 70% coinsurance up to the annual out-of-pocket maximum. Pre-arranged services while outside the area are covered as if in-network.
Out of Network. If my treating dentist is not a participating provider with my insurance, I will be required to pay for all treatment in full, in advance. The practice may file for insurance coverage as a courtesy and apply anything they pay towards my account. If payment from my insurance company results in an overpayment on the account, I will be reimbursed by the practice.
Out of Network treatment by a Dentist who has not signed an agreement with Delta Dental to provide Benefits under the terms of this Contract.
Out of Network. Examination – once a calendar year Covered 100% (after $6.50 co-pay) Optometrist reimbursed up to $28.50 Ophthalmologist reimbursed up to $38.50 Frames – once a calendar year Up to $65 retail Reimbursed up to $44 Lens – once a calendar year Single Bi-focal Tri-focal Lenticular Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Clear/color tints & coats/ polarized $29/$33/$47 reimbursement $51/$61/$81 reimbursement $63/$75/$101 reimbursement $75/$89/$119 reimbursement Contact Lens (in lieu of lens/frame) – once a calendar year Elective Medically necessary (prior authorization is required) Up to $90 Covered 100% Reimbursed up to $90 Reimbursed up to $175
Out of Network. Not covered except for emergent and urgent care as described above, and pre-arranged services while outside the area.
Out of Network. If I am not in your insurance network, the full fee is to be paid at each session at the private pay rate (listed above) and you will be responsible for filing with your insurance for possible reimbursement. If you have questions regarding your coverage, it is recommended that you contact your insurer directly. I will provide a receipt or statement as needed. Cancellations/Missed Appointments: It is important that you keep your scheduled appointments. Appointments not cancelled 24 hours in advance will be billed $100.00 Insurance does not cover these charges therefore we will not submit a claim to your insurance company. Client Signature: Date: Client Name: (Please print): Patient Name: D.O.B: Marital Status: Spouse’s Name: (if applicable) Address: City: State: Zip: Cell Phone: Work Phone: Private/personal Email: May messages be left for you at: Cell? Work? Email? Insurance Information – Please provide a copy of your insurance card(s), front and back, or bring your card(s) to your first appointment so that copies can be made.
Out of Network. Examination – once a calendar year Covered 100% (after $6.50 co-pay) Optometrist reimbursed up to $28.50 Ophthalmologist reimbursed up to $38.50 Frames – once a calendar year Up to $65 retail Reimbursed up to $44 Lenses – once a calendar year Single Bi-focal Tri-focal Lenticular Lenses / photogrey & transition / polarized / tints Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Covered 100% after $18 co-pay Lenses / photogrey & transition / polarized / tints $29 / $18 / $4 reimbursement $51 / $30 / $10 reimbursement $63 / $38 / $12 reimbursement $75 / $44 / $14 reimbursement Elective Contact Lenses (in lieu of lens/frame) – once a calendar year Medically necessary (Prior authorization is required): Up to $90 Covered 100% Reimbursed up to $90 Reimbursed up to $175
Out of Network. Examination – once a calendar year Covered 100% Optometrist reimbursed up to $35 Ophthalmologist reimbursed up to $45 Frames – once a calendar year Up to $65 retail Reimbursed up to $55 Lens – once a calendar year Single Bi-focal Tri-focal Lenticular Covered 100% Covered 100% Covered 100% Covered 100% Clear/ Photogrey or Transition / Polarized / Tints & Coats/ $38 / NA / $18 / $4 reimbursement $60/ NA / $30 / $10 reimbursement $72/ NA / $38 / $12 reimbursement $108/ NA / $30 / $10 reimbursement Contact Lens (in lieu of lens/frame) – once a calendar year Elective Medically necessary (prior authorization is required): Up to $115 Covered 100% Reimbursed up to $115 Reimbursed up to $200
Out of Network. Examination – once a calendar year Covered 100% (after $6.50 co-pay) Optometrist reimbursed up to $28.50 Ophthalmologist reimbursed up to $38.50 Frames – once a calendar year Up to $65 retail Reimbursed up to $44
Out of Network. If you wish to visit a provider who does not participate with the plan, you’ll still be covered for designated services after meeting a deductible and paying coinsurance. Non-participating providers also may charge you for any balance above the maximum allowable amount. Individual deductible: $1,000 Family deductible: $2,000 (2-member family); $2,000 (family of 3 or more) Coinsurance: 30% after deductible, up to the cost-share maximum. Lifetime maximum: In-Network: Unlimited Out-of-network: $1,000,000 per member Managed Benefits: Precertification is required for hospital admissions, certain elective surgical procedures; and other services as specified by the Plan. Members are responsible for obtaining pre-certification for the required services.
