Single Person: $38.00 Two People: $65.00 Family Plan: $95.00 *12 Month Commitment applies to this plan Hearing Aid Discount Free Phone Consultation on Medicaid Planning Receive Prescription Discounts Vitamin Discounts 24 Hour Nurse Hotline Dental Benefits for the Gold Plan Preventive Services: Examples PPO Premier Preventive & Diagnostic Fluorides Emergency Palliative X-Rays Sealants 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% Basic Services: Examples PPO Premier Periodontic Prophylaxes Minor Restorative Simple Periodontics Major Periodontics Endodontics Oral Surgery Relines & Repairs 90% 50% 50% 50% 50% 50% 50% 90% 50% 50% 50% 50% 50% 50% Major Services: Examples PPO Premier Major Restorative Stainless Steel Crowns Prosthodontics 30% 30% 25% 30% 30% 25% Insurance will be effective the first day of the upcoming month. *12 month waiting period applies, waived for current members. Delta Dental Application Form Vision Benefits for the Gold Plan Covered Services Participating Provider Non-Participating Provider Examinations Limited to one examination per benefit period. Covered in full, less any deductible. Plan pays up to $28.00 less any deductible. Frames Limited to one frame per benefit period. Plan pays up to $50.00 less any deductible. You will receive the DeltaVision discount on the retail price of frames before the DeltaVision payment. Plan pays up to $35.00 less any deductible. Lenses (per lens) Limited to one set of lenses per benefit period. Single Vision Covered in full, less any deductible. Plan pays up to $15.00 less any deductible. Bifocal Plan pays up to $22.50 less any deductible. Trifocal Plan pays up to $25.00 less any deductible. Progressive Plan pays up to $42.50 less any deductible. The DeltaVision discount applies. Plan pays up to $25.00 less any deductible. Polycarbonate (for children up to age 18) Plan pays up to $10.00 less any deductible. The DeltaVision discount applies. Plan pays up to $7.50 less any deductible. Other lens options No coverage, however you will receive the DeltaVision discount. No coverage. Contact Lenses Limited to once per benefit period in place of regular lenses. You will receive the lowest price offered by a participating provider. Elective Plan pays up to $105.00 Plan pays up to $105.00 Medically necessary Covered in full. Plan pays up to $210.00 Laser Vision Correction Only one vision correction option (glasses or contacts) is allowed per benefit period. No coverage, however you will receive the DeltaVision discount. No coverage.   *This web page is for illustrative purposes only. You will receive benefit booklets. If there is a discrepancy between this web page and your benefit booklet, the benefit booklet prevails. Renewal rates are effective for 8/15/2010