Surebridge Dental and Vision Plan Options

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Benefits-Network Provider* BASIC PLAN PREMIERE PLAN
Covered Services: Preventive, Diagnostic, Restorative and Adjunctive Services Preventive, Diagnostic, Restorative, Adjunctive, Endodontics, Periodontics, and Oral Surgery Services
Type I 100% - No waiting period and No deductible 100% - No waiting period and No deductible
Type II 50% - 6 month waiting period 80% - 6 month waiting period
Type III Not covered - network discounts 60% - 12 month waiting period
Calendar year deductible $100/person - 3 max per family $50/person - 3 max per family
Calendar year maximum $1,000 per person
$5,000 per family		 $1,200 per person
$6,000 per family
0-64 MONTHLY PREMIUMS* BASIC PREMIERE
Adult $19 $39
Child $16 $28
65-99 MONTHLY PREMIUMS* BASIC PREMIERE
Adult $21 $43

(*see benefit details, exclusions & limitations in attached brochures; rates vary in FL, GA, MA, MD, RI)

  • Premiere Vision Plan At A Glance**
    • 100% coverage for routine eye exam
    • Discounts on contact lenses and additional savings from EyeMed
    • Large network of providers to choose from
    • Coverage is available for the whole family - you, your spouse and your kids
    • Affordable premiums that do not increase as you get older - with Basic coverage starting at $19 per month for an adult under age 65
    • Issue ages: 0-99
    • Brochure/Benefits - 0-64:Brochure
    • Brochure/Benefits - 65-99: Brochure

VISION � Network Provider**
Eye Exam (per 12 month period) 100%, no copay
Standard, Uncoated Plastic Lenses (in lieu of contact lenses) $10 copay
Frames (in lieu of contact lenses) $10 copay with $120 allowance
Corrective Contact Lenses (in lieu of standard uncoated plastic lenses and frames) $10 copay with $120 allowance
0-64 MONTHLY PREMIUMS
Individual $9
2 Persons $16
Family $25
65-99 MONTHLY PREMIUMS BASIC
Individual $10
2 Persons $18

(** see benefit details, exclusions & limitations in attached brochures)