2024-BenefitsGuide-V16-Final

Dental Benefits

Reliance Rewards offers a PPO dental plan administered by Delta Dental of California. It covers preventive, basic, and major dental services on an in-network and out-of-network basis. You may use any dental provider you choose, but you will save the most when you use a dentist who participates in the Delta Dental PPO network. To view dentists in the Delta Dental PPO and Premier networks, go to www.deltadentalins.com/reliancerewards.

IN-NETWORK

OUT-OF-NETWORK

Delta Dental PPO Lower deductible and coinsurance, lowest negotiated rates, no claim forms

Delta Dental Premier Higher deductible and coinsurance, negotiated rates

Non-Delta Dental Higher deductible and coinsurance

Annual Deductible Individual Family

$50 $100

$100 $200

$100 $200

Annual Benefit Maximum – per Individual

$1,500

$1,500

$1,500

Diagnostic & Preventive Services Exams, x-rays, cleanings, fluoride treatments Basic Services Fillings, extractions, sealants, root canals, gum treatment, and oral surgery Major Services Crowns, inlays, onlays, implants, cast restorations, bridges, dentures

No Cost to You, However May be Subject to Balance Billing

No Cost to You

No Cost to You

You Pay 30% after Deductible

You Pay 30% after Deductible

You Pay 10%

You Pay 40% after Deductible

You Pay 50% after Deductible

You Pay 50% after Deductible

Member Responsible for Balance Billing? Orthodontic Services for Children under 26

NO

YES

$750 LifetimeMaximum

Vision Benefits

Vision benefits offered under Reliance Rewards are provided by VSP. The vision plan helps cover the cost of annual eye exams and prescription glasses or contact lenses. Youmay use any eye care provider you choose, but you will save themost when you use a VSP Preferred Provider. VSP also has special offers, including discounts on hearing aids. Visit www.VSP.com for details.

IN-NETWORK

OUT-OF-NETWORK

Eye Exam Once every calendar year

$10 Copay

Up to $45 allowance after $10 Copay

Prescription Glasses

$25 Copay*

$25 Copay*

Covered up to $175 allowance after Copay; 20% off the amount over the allowance

Frames Every other calendar year

Up to $70 allowance after Copay

Single Vision – Up to $45 allowance after Copay Lined Bifocal Vision – Up to $65 allowance after Copay Lined Trifocal Vision – Up to $85 allowance after Copay Covered up to $150 allowance; allowance applies to contact lenses and contact lens exam, fitting, and evaluation

Lenses Once every calendar year

$25 Copay*

Contact Lenses Once every calendar year (Instead of lenses and frames)

Covered up to $175 allowance. Allowance applies to contact lenses and contact lens exam, fitting, and evaluation

*Only one $25 copy applies when receiving frames and lenses

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