Page 10 - 2017-18 Optimas Benefits Guide
P. 10
Dental
Find a Provider Delta Dental of Illinois
1. Go to Delta Dental’s plans give you access to the largest dental provider networks
www.deltadentalil.com in the nation. You have the option between a base and buy-up dental plan. In
and click the provider both plans, you have the freedom to choose any dentist. However, you will
search link. Select “Find receive the deepest savings if you choose a Delta Dental PPO dentist. All
a Network Dentist” from Delta Dental network dentists ile claims for you and your family when you
the drop down menu. provide your identiication card—no paperwork for you!
2. Call 800.323.1743, say
“Dentist Directory” and Delta Dental of Illinois Buy-Up Plan
Base Plan
follow the automated In-Network Base Plan Out- Buy-Up Plan Out-of-
In-Network
of-Network*
instructions. Deductible (Plan Year) Network*
$50
$50
3. Call your dentist’s ofice Individual $100 $100 $25 $25
$75
Family
$75
and ask if they are a Coinsurance—Percent You Pay
participating Delta Dental Preventive Services:
PPO or Premier network Exams, X-Rays, 100% covered 100% covered 100% covered 100% covered
Prophylaxis
dentist. Basic Services: Fillings, 80% after 80% after 80% after 80% after
Oral Surgery, Root
Canals deductible deductible deductible deductible
Major Services: Bridges, 50% after 50% after 50% after 50% after
Crowns, Dentures deductible deductible deductible deductible
Plan Year Maximum
$1,000 $1,000 $2,000 $2,000
Orthodontist Services
Dependent Children 50% no 50% no 50% no 50% no
Adults deductible deductible deductible deductible
Orthodontist Lifetime $1,500 $1,500 $2,000 $2,000
Maximum
* Please note, if you see an out-of-network provider, Delta Dental will reimburse according to the
maximum allowable charge.
Dental Contribution Rates
This chart illustrates your weekly, bi-weekly, and/or monthly pre-tax
contributions for the Optimas dental plan.
Base Plan Buy-Up Plan
All Employees Weekly Bi-Weekly Monthly Weekly Bi-Weekly Monthly
Employee Only $4.04 $8.07 $17.49 $4.90 $9.80 $21.24
Employee + Spouse $9.09 $18.19 $39.41 $10.91 $21.82 $47.28
Employee + Child(ren) $7.77 $15.54 $33.66 $9.32 $18.65 $40.40
Family $13.36 $26.73 $57.91 $16.13 $32.26 $69.90
10 2017–18 Benefits Enrollment
Find a Provider Delta Dental of Illinois
1. Go to Delta Dental’s plans give you access to the largest dental provider networks
www.deltadentalil.com in the nation. You have the option between a base and buy-up dental plan. In
and click the provider both plans, you have the freedom to choose any dentist. However, you will
search link. Select “Find receive the deepest savings if you choose a Delta Dental PPO dentist. All
a Network Dentist” from Delta Dental network dentists ile claims for you and your family when you
the drop down menu. provide your identiication card—no paperwork for you!
2. Call 800.323.1743, say
“Dentist Directory” and Delta Dental of Illinois Buy-Up Plan
Base Plan
follow the automated In-Network Base Plan Out- Buy-Up Plan Out-of-
In-Network
of-Network*
instructions. Deductible (Plan Year) Network*
$50
$50
3. Call your dentist’s ofice Individual $100 $100 $25 $25
$75
Family
$75
and ask if they are a Coinsurance—Percent You Pay
participating Delta Dental Preventive Services:
PPO or Premier network Exams, X-Rays, 100% covered 100% covered 100% covered 100% covered
Prophylaxis
dentist. Basic Services: Fillings, 80% after 80% after 80% after 80% after
Oral Surgery, Root
Canals deductible deductible deductible deductible
Major Services: Bridges, 50% after 50% after 50% after 50% after
Crowns, Dentures deductible deductible deductible deductible
Plan Year Maximum
$1,000 $1,000 $2,000 $2,000
Orthodontist Services
Dependent Children 50% no 50% no 50% no 50% no
Adults deductible deductible deductible deductible
Orthodontist Lifetime $1,500 $1,500 $2,000 $2,000
Maximum
* Please note, if you see an out-of-network provider, Delta Dental will reimburse according to the
maximum allowable charge.
Dental Contribution Rates
This chart illustrates your weekly, bi-weekly, and/or monthly pre-tax
contributions for the Optimas dental plan.
Base Plan Buy-Up Plan
All Employees Weekly Bi-Weekly Monthly Weekly Bi-Weekly Monthly
Employee Only $4.04 $8.07 $17.49 $4.90 $9.80 $21.24
Employee + Spouse $9.09 $18.19 $39.41 $10.91 $21.82 $47.28
Employee + Child(ren) $7.77 $15.54 $33.66 $9.32 $18.65 $40.40
Family $13.36 $26.73 $57.91 $16.13 $32.26 $69.90
10 2017–18 Benefits Enrollment
