Page 5 - First Bank- Open Enrollment Guide 2015
P. 5
First Bank
Dental Plan Options—Delta Dental
First Bank offers dental coverage through the Delta Dental PPO Dental
Network, the largest dental network in the United States. You may
choose to participate in one of two plans called “Option A” and
“Option B”. The Option A Plan provides a higher level of beneit and
requires a higher per pay period employee contribution. The Option B
Plan carries a lower per pay period cost but provides coverage on basic
and restorative services only. Because this is a PPO Plan, participants
may obtain services outside the Delta Dental PPO network; however,
copayments outside the PPO network will be greater. Services obtained
from providers in the Delta Dental Premier network who are not
members of the Delta Dental PPO network are considered out-of-
network services in this Plan.
Dental services are covered as indicated in the following schedule.
Out-of-
Covered Beneits—Option A In-Network Network
A. Diagnostic and preventive services 100% 100%
B. Basic and restorative services 85% 80%
C. Major services 60% 50%
D. Orthodontia (children to age 19) 40% 40%
Individual deductible (applies to B and C above $50 $50
only)
Family deductible (applies to B and C above only) $150 $150
Maximum beneit per person per year (excl. ortho) $1,500 $1,500
Maximum lifetime orthodontia beneit (per child) $1,500 $1,500
Out-of-
Covered Beneits—Option B In-Network Network
A. Diagnostic and preventive services 100% 100%
B. Basic and restorative services 80% 50%
C. Major services N/A N/A
D. Orthodontia (children to age 19) N/A N/A
Individual deductible (applies to B above only) $50 $50
Family deductible (applies to B above only) $150 $150
Maximum beneit per person per year $1,000 $1,000
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Dental Plan Options—Delta Dental
First Bank offers dental coverage through the Delta Dental PPO Dental
Network, the largest dental network in the United States. You may
choose to participate in one of two plans called “Option A” and
“Option B”. The Option A Plan provides a higher level of beneit and
requires a higher per pay period employee contribution. The Option B
Plan carries a lower per pay period cost but provides coverage on basic
and restorative services only. Because this is a PPO Plan, participants
may obtain services outside the Delta Dental PPO network; however,
copayments outside the PPO network will be greater. Services obtained
from providers in the Delta Dental Premier network who are not
members of the Delta Dental PPO network are considered out-of-
network services in this Plan.
Dental services are covered as indicated in the following schedule.
Out-of-
Covered Beneits—Option A In-Network Network
A. Diagnostic and preventive services 100% 100%
B. Basic and restorative services 85% 80%
C. Major services 60% 50%
D. Orthodontia (children to age 19) 40% 40%
Individual deductible (applies to B and C above $50 $50
only)
Family deductible (applies to B and C above only) $150 $150
Maximum beneit per person per year (excl. ortho) $1,500 $1,500
Maximum lifetime orthodontia beneit (per child) $1,500 $1,500
Out-of-
Covered Beneits—Option B In-Network Network
A. Diagnostic and preventive services 100% 100%
B. Basic and restorative services 80% 50%
C. Major services N/A N/A
D. Orthodontia (children to age 19) N/A N/A
Individual deductible (applies to B above only) $50 $50
Family deductible (applies to B above only) $150 $150
Maximum beneit per person per year $1,000 $1,000
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