NDPERS VISION PLAN Underwritten by Ameritas

Document Sample
NDPERS VISION PLAN Underwritten by Ameritas Powered By Docstoc
					NDPERS                                            VISION PLAN                                                         Underwritten by Ameritas


PLAN ADVANTAGES

   Easy to understand.
   Affordable price, convenient payroll deduction.
   Freedom to choose your own optometrist.
   Participants can take advantage of special promotions, sales and discounts.
   Participants file their own claims and know in advance exactly what benefits will be.
   Toll-free telephone number directs you to specially trained staff that can answer your questions quickly and efficiently.
   Four-tier premium structure designed to accommodate your specific coverage needs.



SERVICES COVERED
                                                                                              Plan Pays
         Vision Exam (Once every 12 months)*                                                  $40.00
         Frames (Once every 12 months)*                                                       $40.00
         Lenses (Once every 12 months) – per pair of lenses*
                 Single vision                                                                $35.00
                 Bifocal                                                                      $50.00
                 Trifocal                                                                     $65.00
                 No-line bifocal or progressive power                                         $70.00
         Lenticular                                                                           $70.00
         Contact lenses (Once every 12 months)*                                               $75.00


DEDUCTIBLE

   Lifetime deductible per person –applies to frames and contact lenses only                           $40.00
         *The benefit paid will be the lesser of the actual amount charged or the benefit shown above. You will be responsible for
          any cost over the plan benefit amounts. Benefits will be paid for glasses or contact lenses, but not both each 12 months.



PREMIUM RATES
                                                                                              Monthly Rates
         Employee only                                                                          $ 5.16
         Employee & Spouse                                                                      $ 10.32
         Employee & Child(ren)                                                                  $ 9.40
         Employee, Spouse & Child(ren)                                                          $ 14.56


LATE ENTRANTS

   A Late Entrant is any eligible employee who enrolls in the plan after the expiration of their initial enrollment period (i.e. 31 days from
    either their employment date or the occurrence of a life change event).
   May only enroll during a subsequent annual enrollment season.
   Only receive the $40 examination benefit for their first 12 months of coverage.

This summary of benefits is intended to describe only a general outline and does not represent the actual terms and conditions of
the policy. The vision handbook and claim forms are available at www.state.nd.us/ndpers.


For questions concerning coverage call 1-800-255-4931 (policy #350308)