Dental, Vision, & Insurance Benefits FEDERAL & POSTAL EMPLOYEES+
50 State Insured Dental & Eye Care
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Insured Free Choice 50+ States Page 2
50 State Insured Dental & Eye Care
Application & Payroll Deduction Forms
Direct Deposit from your Checking Account or Pay Check-you may pay Premium & Enrollment Fees DHMO
California Dental HMO Plans with VisionCare
Texas Dental HMOs With Vision Benefits
Dental HMO Plans in states other then CA or TX OK to enroll from DC-PR-VI & APO Addresses
Vision Benefits That Are with the Dental HMO Plans Vision with the PPO is an Insured Plan
Dental & PPO or go to any dentists in California Blue Cross
Disability - Life - Cancer Insurance Plans
Brochures you may VIEW or DOWNLOAD

Ameritas Group a UNIFI CO with over $ 25 Billion of Consolidated Assets

FUSION: THE ULTIMATE CHOICE PRODUCT DESCRIPTIONS

        Employee receives dental and eye care benefits in one plan at an affordable price.

       Plan maximums and frequencies are combined for dental and eye care.  Members may visit any dentist or eye care office and receive benefits -- this cost-saving plan is available everywhere.  Simply you may go anywhere.

        

FUSION Combined Dental and Eye Care Plans then you may see your good teeth!

click here to see benefits and detail schedule

click here to orthodontic coverage with PPO for children

EYE CARE LIMITATIONS PAGE VISION PERFECT  Eye Med >(LUX NYSE Exchange)

 

Reimbursements with service at “any vision office”

for the Ameritas Fusion Plan to Subscribers 

 

Subscriber using contracted Eye Med offices have a maximum fee that may be charged.

Examples: ** Single Vision Lenses $50, Bifocal $70, Trifocal $105 any frame 35% off retail price

 

EYE CARE PLAN HIGHLIGHTS             

These benefits are paid to any vision office  

Deductible - Calendar Year Deductible:   $25

Exams, Lenses (other than contact lenses) or

Frames/Contact                             

Maximum - Exams and Materials -

Per Benefit Period Paid by the Insurance Company None


SERVICE  Examination

Includes case history; external examination of the eye and adnexa; ophthalmoscopic examination; determination of refracture status; binocular balance; tonometry test for glaucoma; gross visual field when indicated; summary finding; prescribing of lenses.

Frames

Lenses (Per pair of lens - Patient pays remainder)

 Single  $40  Bifocal  $ 60 Trifocal  $ 75 

Eye Med Providers have a maximum fee that they may charge for additional savings

Single $50 Bifocal $70 $ Trifocal $105 thus you would pay only the difference

No line bifocal or progressive power & Lenticular   $80

See Maximum fees providers may charge and compare.Contact Lenses (annual per year per family member) $120

Frequency Allowance

Exam                          12 Months

Lens                           12 Months

Frames                       24 Months

Administrator:  www.fdvp.com  email info@fdvp.com

click here to view or download eye care benefits

application, 1199 payroll deduction form, credit card, or bank draft use

click here to download bank draft & DHMO Premiums

Email Questions> we will do comparisons with other plans and how our Plans would work for you!

Online Application click to submit below when finished.
 
The Fusion Ameritas PPO Plan is separate and not related or affiliated in anyway whatsoever to the Dental HMO plans that are provided by different companies.  These plans are provided to give you more options by your group.
 
Please, answer all questions, if you have a question on premium amount or anything please email us below.
 
If you wish to make a payment and you are already enrolled you may provide your information here and indicate it is only a payment at the last question
 
The Fusion Dental & Vision Plan includes the PPO option.
If you wish to have this plan and a Dental HMO then you would select "both" in the online application below.

Name: Last, First, Mi as it appears on your pay check or retirement check
Social Security # for claiming of premiums only not used as an ID
Employer -Agency & Location if Retired from where?
Dental Plan Selected: example: 550V, 13V, ANTX, 110V, HO, or Free Choice Fusion with PPO. You may have BOTH DHMO & Fusion with PPO; Type E1, E2, or E3
Home Street
Home City
Home State
Home Zip + 4 if you know it
Home Area Code
Home Phone
Home Fax
Primary Email Address:even though you are submitting on line we will not have your email address if you do not add it here
Work Street
Work City
Work State
Work Zip + 4 if you know it
Work Phone Area Code
Work Phone
Work Fax
Work Email
Date of Birth (example 07/11/1979)
Spouse Name
Spouse Date of Birth (09/25/1980)
Name Child(ren) & Date of Birth
Premium Mode - How you wish to pay?: Payroll Deduction, A, SA, Q, CHECK-O-MATIC, or CCPayroll deduction
Check-O-Matic-Bank Draft
Annual >DHMOs only
Semi-Annual >DHMOs only
Quarterly
Credit Card [MC-VISA only]
Premium Amount (we will inform you of needed corrections) if unsure please ask prior to input to Payroll. Let us help you.
Have you started or will you start shortly your payroll deduction with your employer through Employee Express or NFC National Finance Center or PostalEASE?? & any questions? Yes or No?
Yes, Insured Free ChoiceFusion Plan by Ameritas Group with PPO optionYes, I want Insured Fusion Denta & Vision Plan with Free Choice of providers & PPO option
No, I do not want Fusion Plan with Free Provider Choice & PPO included
I WANT BOTH Fusion PPO & Dental HMO & will be paying a premium for each
I want dental HMO with Vision & not Ameritas PPO
Which Fusion with Free Provider Choice & PPO Plan do you select? Please, select the Insured Free Choice Plan You Want?Plan E1 High Level Benefits
Plan E2 Mid Level Benefits
Plan E3 Standard Benefits
NO Fusion Free Choice with PPO
I only want the DENTAL HMO with Vision
Yes or No for Dental HMO _Panel OnlyYes, I want the Dental HMO with Vision
No, I do not want Dental HMO with Vision
I Want BOTH DHMO & Fusion Free Choice with PPO & I will be paying 2 premiums
I want one of the PPO Plans E1.E2.or E3
DENTAL HMO select the plans dental office by typing in the DDS Code# no pre-provider selection required for the Fusion Plan with PPO
After reading and understanding this section PLEASE CLICK THE BOX TO THE RIGHT. In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete or misleading information in an application for insurance or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. If a required premium increase occurs and the client does not change the payroll deduction (if payroll deduction is selected), which he/she understands would be necessary and required then the amount the administrator may change the client/subscribers plan to a different plan coverage, and company. As an employee/member, I hereby apply for insurance or health benefits, for which I am eligible or may become eligible. This information was explained in the plan solicitation materials, and enrollment is for a minimum of twelve months, which I have read and understand. PLEASE CLICK BOX TO THE RIGHTYes I accept and understand
Please Confirm TYPE IN THE:> Premium, Plan & Mode of Payment (example: Payroll, Bank Draft, Credit Card, Direct Bill Q, SA, or Annual, Plan ie E1,E2,E3,-HO-550V-110-ANTX etc.
Use Bank Draft Check-O-Matic. (Lower cost then quarterly direct bill or credit card).Click to RIGHT so we know what you Want
Expedite Enrollment with payment by Bank Draft Input Routing # & Bank Account # also download check-o-matic form and mail or fax with voided check
To Expediate Enrollment by Credit Card or other Options Click to right PLEASE SEE OTHER OPTIONS
Credit Card Payment by MC or VIsa input your credit card type; number, expiration date, & last 3 digit security code from the back of your card.
Name as it appears on Credit Card
Credit Card Billing Address
Confirm 3 digit (end of #s) Credit Card Security Code from back of credit card
I understand I will be mailing a copy of the payroll deduction form with the enrollment fee if applicable CLICK IF YESYes I will be sending in a copy of the 1199 after I go to PostalEASE, NFC, or Employee Express
I will be mailing the Premium and Enrollment Fee for the Direct Premium for Fusion only Quarterly is available DHMOs SA & Annual are availabale
I will be mailing the Enrollment Fee
I wish the enrollment fee paid by check-O-Matic
I wish the enrollment fee paid by credit card and understand there is an additional handling fee
I will not be making any payment by Bank Draft
Enrollment Fee Paid By What Method?
NAME of Agency-Employer?
For Postal Employees Only. Are you an APWU Member?I am an APWU Member
I am not an APWU Member
If an APWU member my APWU Local is? & Phone#
How many brochures may we send for the people you work with?
> IF YOU WISH TO ADD non immediate family members to your plan you may. They will PAY THE PREMIUM of a Single Adult (couple or family) additional to your BASIC PREMIUM. We need their Name, Date of Birth, Social Security #, # of additional people and their relationship: (example: Over Age Child(ren), Grand Child(ren), Parent(s), Domestic Partner, Sibling(s), those that need coverag. You may have them pay the premium because of you or add to your premium.
I have a Questions?
Are you interested in receiving information on additional insurance-do not worry we will not be sending an agent.yes
no
Disability Insuranceyes
no
Cancer additional lump sum benefityes
no
Life Insurance with 3 questions? 1. Are you working today? 2. Do you have Aids? 3. Missed work in last 3 months?Yes, send me info on life insurance
No Thank You we have plenty of Life Insurance
Comments
If making a payment on an existing account include the Plan#
  

To see the submit button to click go all the way to the right and click once  >
 
*****
No need to pre-select Eye Care offices for the Eye Care benefits with either the Dental HMOs (discount from Coast to Coast) or the Fusion 50 State +DC Plan with "free choice" of Eye Care office and receive insurance reimbursement or use contracted offices for added advantages.
 
*****
Eligibility is the First of the Month after the second payroll deduction (or first of the month after Expediting Enrollment by Credit Card, Bank Draft, or Quarterly and the premium and all requirements are received by the administrator AMA
 
Postal Employees are required to return a signed copy, in two places, of the alloment form and authorization, and writing "copy" on it even though they have started payroll deduction by "PostalEASE."
 
 

click here to view or download PostalEASE information

Thank you for enrolling.  If you did not provide a primary email address above, even though you enrolled online we did not receive information on your email address this was setup this way for your privacy.

 

You will now need to download the 1199 Payroll Deduction Form and mail it with the $20 Enrollment Fee for all Fusion PPO Plans with Free Choice of Dental or Eye Care Provider, regardless of family size to American Marketing Administrators. (AMA).

 

To pay the enrollment fee you may fax or mail a copy of the 1199 Payroll Deduction form and use Check-O-Matic or provide credit card information, an additional shipping and handling fee applies to credit card use, to (AMA).

 

The enrollment fee for the Dental HMO Plans is $20.  Check payable to American National Dental or use credit or debit card.

 

Credit Card number, expiration date, name on the card, 3 digit security code from the back of the card, and the billing address for the credit card if it is different.  You may email this to:

        payments@federaldentalportal.com

 

If you wish to pay by direct (such as) quarterly you will also need to include the premium for the direct bill.

 

If you wish to expedite enrollment by either a bank draft use the Check-O-Matic form or provide credit card information (MC & VISA only), mail or                                                                                                               

 

 fax (818-223-8147  alternate fax 818-992-4438)

Nominate a Provider Click Here for the PPO Fusion Plan; Claim Forms; Enroll Dependent Under Disabled Status.

American Marketing Administrators, Inc.
Ameritas Group Federal & Postal Employees Dental & Vision Plans
Insurance Agency & Registered Insurance Administrator Since 1980
23901 Calabasas Road Suite 2014
Calabasas, CA 91302-3307     Email: info@fdvp.com
818-223-9750, Fax 818-223-8147, 800-300-PLAN
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