City of Nacogdoches 2021 Enrollment Guide

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DENTAL INSURANCE CONTRACTING DENTIST NON-CONTRACTING DENTIST Diagnostic Services Oral evaluations Radiographs Films Preventive Services Prophylaxis (cleanings) Topical fluoride applications Sealants Space maintainers Basic Services Amalgams Resin-based composite restorations Non-surgical extractions Deep sedation / general anesthesia Palliative treatment Oral surgery Major Services Single crown restorations Inlay/Onlay restorations Labial veneer restorations Crowns placed over implants Periodontal scaling and maintenance Full mouth debridement Endodontic services Surgical Periodontal services Restorative and Prosthodontic services Crown/bridge repairs Adjustments Recemenations Orthodontics Diagnostic procedures Treatment 100% 100% 100% 100% 80% 80% 50% 50% 50% 50% When the course of treatment will be in excess of $300, a predetermination request should be submitted to BCBSTX in advance of treatment. 18
VISION INSURANCE - HIGH PLAN CARRIER: LINCOLN FINANCIAL NETWORK: SPECTERA ● You will pay less out of pocket when you choose an in-network provider. ● Locate an in-network provider at www.myspectera.com. ● You must submit a claim form for out-of-network expenses. ● LASIK surgery discounts available ELECTION MONTHLY EMPLOYEE COST Employee Only $9.33 Employee & Spouse $17.68 Employee & Child(ren) $20.75 Employee & Family $29.19 COVERED BENEFITS IN-NETWORK OUT-OF-NETWORK Eye Exam (every 12 months) $10 copay Up to $40 reimbursement Lenses (every 12 months) Single: 100% after $10 copay Bifocal: 100% after $10 copay Trifocal: 100% after $10 copay Lenticular: 100% after $10 copay Single: $40 copay reimbursement Bifocal: $60 copay reimbursement Trifocal: $80 copay reimbursement Lenticular: $80 copay reimbursement Frames (every 12 months) Up to $130 allowance Up to $45 reimbursement Contact Lenses (every 12 months) Elective Covered Medically Necessary Up to $125 allowance 100% after $10 copay 100% after $10 copay Up to $125 reimbursement Up to $125 reimbursement Up to $210 reimbursement 19
Page 1 and 2: EMPLOYEE BENEFITS ENROLLMENT GUIDE
Page 3 and 4: CONTENTS 04 Benefits Overview 06 Me
Page 5 and 6: BENEFITS OVERVIEW ELIGIBILITY Full-
Page 7 and 8: MEDICAL INSURANCE CARRIER: BLUE CRO
Page 9 and 10: VIRTUAL VISITS / MDLIVE When it com
Page 11 and 12: 11
Page 13 and 14: FLEXIBLE SPENDING ACCOUNTS Why not
Page 15 and 16: FLEXIBLE SPENDING ACCOUNTS 15
Page 17: DENTAL INSURANCE CARRIER: BLUE SHIE
Page 21 and 22: BASIC LIFE AND AD&D INSURANCE CARRI
Page 23 and 24: 23
Page 25 and 26: VOLUNTARY LIFE INSURANCE CARRIER: L
Page 27 and 28: LONG TERM DISABILITY INSURANCE CARR
Page 29 and 30: ENROLLMENT INSTRUCTION The City of
Page 31 and 32: IMPORTANT CONTACTS BENEFIT CARRIER

City of Nacogdoches 2021 Enrollment Guide

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