DENTAL & VISION

DENTAL

HL offers two Dental Plans with Cigna to select. The Cigna High Plan and Cigna Low Plan are both part of Cigna’s Total Cigna DPPO network of providers.

Services	Low Plan	High Plan
Annual Deductible (Individual/Family)	$50 / $150	$50 / $150
Annual Maximum	$2,000	$3,000
Preventive & Diagnostic	100%, No deductible	100%, No deductible
Basic Restorative Care	80%, After deductible	100%, After deductible
Major Restorative Care	50%, After deductible	60%, After deductible
Orthodontia	Not Covered	50%, No ortho deductible Lifetime Maximum: $1,500
Implants	50%, After deductible Lifetime Maximum: $2,000	60%, After deductible Lifetime Maximum: $3,000
Reimbursement Levels	MAC	90th UCR
# of Cleanings	2	3

Summary of Benefit Coverages - Low Plan

Summary of Benefit Coverages - High Plan

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VISION

Our Vision Plan through EyeMed provides coverage for eye exams, glasses, or contacts. Our Vision Plan is part of the EyeMed Select Network of providers.

Services & Frequency	In-Network Coverage	Out-of-Network Reimbursement
Exam Frequency	Once every 12 months	Once every 12 months
Eyeglasses (Lenses & Frames) or Contact Lenses Frequency	Once every 12 months	Once every 12 months
Frames Frequency	Once every 24 months	Once every 24 months
Eye Exam	$10 copay	Up to $30
Frames	$0 copay, $130 allowance; 80% of charge over $130	Up to $65
Single Vision Lenses	$25 copay	Up to $25
Bifocal Lenses	$25 copay	Up to $40
Trifocal Lenses	$25 copay	Up to $60
Lenticular Lenses	$25 copay	Up to $60
Standard Progressive Lenses	$90 copay	Up to $40
Conventional Contact Lenses	$0 copay, $130 allowance; 15% off of charge over $130	Up to $104
Disposable Contact Lenses	$0 copay, $130 allowance; 100% of balance over $130	Up to $104

Summary of Benefit Coverages

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Income Protection Benefits