Plan Information
Starmount Increasing Max 2.0 + Vision Plan Schedule of Covered Services and Copayments
This plan rewards your loyalty by increasing your annual maximum from $1,000 per covered person in year one, up to $1,500 per person in year three*. Members further reduce out-of-pocket costs for any services through our national network of 323,000+ dentist access points. ** Services not covered by your plan may still be eligible for in-network discounts from providers who offer discounts.***
Schedule of Covered Services and Copayments | ||||
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* First three years. Subject to policy deductible, annual maximum and limitations and exclusions. ** If you use an out-of-network dentist, benefits are paid based on the network-negotiated rate, and you may be billed for any remaining amount up to the billed charge. *** Not an insured benefit. |
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Plan Pays | ||||
Year 1 | Year 2 | Year 3 | ||
Preventive/Diagnostic No waiting periods |
|
100% | ||
Basic Services No waiting periods |
|
80% | ||
Major Services No waiting periods |
|
10% | 25% | 50% |
Deductible (For Basic and Major Services Only) |
Per person, per benefit year. |
$50 $150 |
||
Benefit Year Maximums (Applies to all services) |
Per person, per benefit year. | $1,000 | $1,250 | $1,500 |
Insured Vision Plan - Outline of Benefits
Freedom of Choice
We offer a national network of participating vision providers. Our provider panel includes independent optometrists and ophthalmologists, as well as regional and national retail chains (including Walmart Vision Center, Sam’s Club Optical, Costco*, Pearle Vision, Target, Sears, JCPenney and Visionworks). Also, you may choose different providers for vision exam and materials purchases.
Additional Savings! Save on additional pairs of glasses, contact lenses and more! Our Value Added or Service Plus providers offer special negotiated fees and discounts for extra purchases of lenses and coatings, frames, contact lenses and other products
Vision Outline of Benefits | ||
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* Special payment and reimbursement terms apply for material purchases at Costco. | ||
Services (In-Network) |
Out of Network Allowance |
|
Exams |
$15 Co-pay $20 Co-pay |
Up to $35 Co-pay See below |
Standard Plastic Lenses | ||
Single Vision Bifocal Trifocal Lenticular Progressive |
Covered by Co-pay Covered by Co-pay Covered by Co-pay $80 Allowance $70 Allowance |
Up to $25 Up to $40 Up to $50 Up to $50 Up to $40 |
Frames | $120 Retail Frame Allowance | Up to $50 |
Contact Lenses (includes fit, follow-up and materials and are in lieu of frames and lenses) |
$20 copay | |
Elective Medically Necessary |
$120 Retail Allowance $210 Retail Allowance |
Up to $100 retail Up to $210 retail |
Underwritten and administered by Starmount Life Insurance Company. Please Note: A full listing of covered procedures will be provided with your policy. This website is not a contract of insurance. This is a brief description of the plan and should be used only as a guide. It does not contain complete plan details. Terms and conditions, including a complete list of benefits, limitations and exclusions, are defined in the policy issued following enrollment in the plan. If questions arise concerning coverage, the policy will govern. Not available in all states. Rates and benefits may vary by state. Policy form series IDN2016P.