Page 21 - Busey Corporation 2022 Benefits Guide
P. 21
2022 Benefits Guide
Dental
We partner with Guardian to ofer you In-Network Out-of-Network
comprehensive dental coverage. Our dental plan Calendar Year Deductible
makes dental care more afordable for associates Individual $50 $50
and their families. Keep in mind, the information Family $150 $150
Coinsurance
in the chart provided is a summary only. Please Preventive 100% 100%
refer to your Certiicate of Coverage (COC) for Basic 80% 80%
complete details on the Beneits Portal. Major 50% 50%
Calendar Year Maximum
Visit www.guardiananytime.com. $1,250 $1,250
Orthodontia
Coinsurance 50% 50%
Benefit Compensation Lifetime Maximum $1,500 $1,500
Beneit Levels Beneit Levels Beneit Applies To Children under age 20 Children under age 20
Bi-Weekly Rates Visits and Exams
2–5 6–10
Associate Only $9.90 $11.42 Visit for Oral Once every 6 months Once every 6 months
Examination
Associate + Spouse/ $22.84 $25.88 Prophylaxis,
Domestic Partner Including Scaling Once every 6 months Once every 6 months
Associate + Child(ren) $28.39 $32.17 and Polishing
Family $46.41 $52.60 Fluoride Once every 6 months Once every 6 months
Children under age 19 Children under age 19
Once every 6 months Once every 6 months
Sealants
Guardian offers a maximum Children under age 19 Children under age 19
rollover feature. Here’s how X-Rays
2 per beneit year
2 per beneit year
it works: Bitewing X-Rays Once every 60 months Once every 60 months
Full Mouth X-Rays
If you incur $600 or less of dental claims during Endodontics
the plan year, you are allowed a maximum rollover Pulpotomy Covered at 80% Covered at 80%
amount of $300 to be added to your plan maximum Apicoectomy Covered at 80% Covered at 80%
for future years. As an added bonus, if you saw only Minor Restorations
in-network providers during the plan year, you will Amalgam (silver)
receive an additional $150 towards your annual Fillings Covered at 80% Covered at 80%
maximum amount. Composite Fillings
(anterior teeth Covered at 80% Covered at 80%
only)
To Find a Dental Provider Stainless Steel Covered at 80% Covered at 80%
1. Go to www.guardiananytime.com Crowns
Uncomplicated
2. Select “Find a dental or vision provider” at the Extractions Covered at 80% Covered at 80%
bottom of the page Surgical Removal
of Erupted Tooth Covered at 80% Covered at 80%
3. Select “PPO” as plan type and enter ZIP code, Inlays Covered at 50% Covered at 50%
then press “Search”
Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%
Full and Partial Covered at 50% Covered at 50%
Dentures
Denture Repairs Covered at 50% Covered at 50%
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Dental
We partner with Guardian to ofer you In-Network Out-of-Network
comprehensive dental coverage. Our dental plan Calendar Year Deductible
makes dental care more afordable for associates Individual $50 $50
and their families. Keep in mind, the information Family $150 $150
Coinsurance
in the chart provided is a summary only. Please Preventive 100% 100%
refer to your Certiicate of Coverage (COC) for Basic 80% 80%
complete details on the Beneits Portal. Major 50% 50%
Calendar Year Maximum
Visit www.guardiananytime.com. $1,250 $1,250
Orthodontia
Coinsurance 50% 50%
Benefit Compensation Lifetime Maximum $1,500 $1,500
Beneit Levels Beneit Levels Beneit Applies To Children under age 20 Children under age 20
Bi-Weekly Rates Visits and Exams
2–5 6–10
Associate Only $9.90 $11.42 Visit for Oral Once every 6 months Once every 6 months
Examination
Associate + Spouse/ $22.84 $25.88 Prophylaxis,
Domestic Partner Including Scaling Once every 6 months Once every 6 months
Associate + Child(ren) $28.39 $32.17 and Polishing
Family $46.41 $52.60 Fluoride Once every 6 months Once every 6 months
Children under age 19 Children under age 19
Once every 6 months Once every 6 months
Sealants
Guardian offers a maximum Children under age 19 Children under age 19
rollover feature. Here’s how X-Rays
2 per beneit year
2 per beneit year
it works: Bitewing X-Rays Once every 60 months Once every 60 months
Full Mouth X-Rays
If you incur $600 or less of dental claims during Endodontics
the plan year, you are allowed a maximum rollover Pulpotomy Covered at 80% Covered at 80%
amount of $300 to be added to your plan maximum Apicoectomy Covered at 80% Covered at 80%
for future years. As an added bonus, if you saw only Minor Restorations
in-network providers during the plan year, you will Amalgam (silver)
receive an additional $150 towards your annual Fillings Covered at 80% Covered at 80%
maximum amount. Composite Fillings
(anterior teeth Covered at 80% Covered at 80%
only)
To Find a Dental Provider Stainless Steel Covered at 80% Covered at 80%
1. Go to www.guardiananytime.com Crowns
Uncomplicated
2. Select “Find a dental or vision provider” at the Extractions Covered at 80% Covered at 80%
bottom of the page Surgical Removal
of Erupted Tooth Covered at 80% Covered at 80%
3. Select “PPO” as plan type and enter ZIP code, Inlays Covered at 50% Covered at 50%
then press “Search”
Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%
Full and Partial Covered at 50% Covered at 50%
Dentures
Denture Repairs Covered at 50% Covered at 50%
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