Page 10 - 2018-19 US Tool Benefit Guide
P. 10
2018–19 Benefits Enrollment
DENTAL
Dental coverage
provided by Delta Dental Benefits
Dental. We partner with Delta Dental to offer you and your family members
dental insurance. Visit www.deltadental.com to ind in-network providers
and access a variety of online tools and programs.
Orthodontia Services Note
The lifetime maximum illustrated Lawful spouses and legally dependent children up to age 19, or age 25 if
is different from the calendar they are a full-time student with 12 credit hours or more, are eligible for
year maximum. For orthodontia the dental plan. Please note full-time student status requires veriication
services, this limit does not twice annually (spring and fall semester) by providing a class schedule,
reset each year, this is the most letter from the school, or tuition billing statement.
your plan will cover for your Dental Beneits At-a-Glance
services for the lifetime of your PPO Dentist Premier Dentist Non-Participating
participation in this program. Dentist
Deductible Single: $50 Single: $50 Single: $50
Examples of Services Family: $150 Family: $150 Family: $150
z Preventive—exams, cleanings, Annual Maximum $1,000 per person $1,000 per person $1,000 per person
luoride, x-rays, and space Preventive Care Covered at 100% Covered at 100% Covered at 100%
80% after
maintainers Basic Care 90% after 80% after deductible
deductible
deductible
z Basic—illings, extractions, Major Care 60% after 50% after 50% after
periodontics, and sealants deductible deductible deductible
z Major—crowns, inlays, Orthodontia 50% after 50% after 50% after
Coinsurance
dentures, dental impacts, and deductible deductible deductible
oral surgery Lifetime Maximum $1,000 $1,000 $1,000
Beneit Applies to Adults and children Adults and children
Remember to visit in-network
dentists to receive the deepest Dental
level of discount on your services.
Dental Rates
To ind a participating in-network Weekly
dentist in your area go to Employee Only $2.16
www.deltadental.com and select Employee and Spouse $4.93
the type of dentist and type of Employee and Child(ren) $5.55
plan you want to search on the
home screen. Employee and Family $8.32
10
DENTAL
Dental coverage
provided by Delta Dental Benefits
Dental. We partner with Delta Dental to offer you and your family members
dental insurance. Visit www.deltadental.com to ind in-network providers
and access a variety of online tools and programs.
Orthodontia Services Note
The lifetime maximum illustrated Lawful spouses and legally dependent children up to age 19, or age 25 if
is different from the calendar they are a full-time student with 12 credit hours or more, are eligible for
year maximum. For orthodontia the dental plan. Please note full-time student status requires veriication
services, this limit does not twice annually (spring and fall semester) by providing a class schedule,
reset each year, this is the most letter from the school, or tuition billing statement.
your plan will cover for your Dental Beneits At-a-Glance
services for the lifetime of your PPO Dentist Premier Dentist Non-Participating
participation in this program. Dentist
Deductible Single: $50 Single: $50 Single: $50
Examples of Services Family: $150 Family: $150 Family: $150
z Preventive—exams, cleanings, Annual Maximum $1,000 per person $1,000 per person $1,000 per person
luoride, x-rays, and space Preventive Care Covered at 100% Covered at 100% Covered at 100%
80% after
maintainers Basic Care 90% after 80% after deductible
deductible
deductible
z Basic—illings, extractions, Major Care 60% after 50% after 50% after
periodontics, and sealants deductible deductible deductible
z Major—crowns, inlays, Orthodontia 50% after 50% after 50% after
Coinsurance
dentures, dental impacts, and deductible deductible deductible
oral surgery Lifetime Maximum $1,000 $1,000 $1,000
Beneit Applies to Adults and children Adults and children
Remember to visit in-network
dentists to receive the deepest Dental
level of discount on your services.
Dental Rates
To ind a participating in-network Weekly
dentist in your area go to Employee Only $2.16
www.deltadental.com and select Employee and Spouse $4.93
the type of dentist and type of Employee and Child(ren) $5.55
plan you want to search on the
home screen. Employee and Family $8.32
10
