Page 10 - NextCare Holdings 2021 Annual Benefits Enrollment
P. 10
Example Services Dental
Preventive—oral Examinations, prophylaxis, bitewing NextCare offers dental insurance through Delta
x-rays, x-rays, topical luoride applications, sealants,
and space maintainers Dental of Arizona. Delta Dental has a unique two-
Basic—illings, injections of antibiotic drugs, tiered network of PPO and Premier providers
extractions, emergency palliative treatment, meaning a large network of options for your dental
anesthesia, consultations, repairs, relining and care.
rebasing, endodontics, periodontics, and oral surgery
Major—crowns, inlays, on lays, bridges, and dentures Providers in these networks will never “balance bill”
Balance Billing participants or charge more than the agreed upon
rates for services. Discounts may be deeper in the
Participating providers have agreed to speciic prices for PPO network versus the Premier network. Talk to
procedures in our plan . When you visit non-participating
providers, your cost for services may be more than our your dentist about how they participate.
negotiated rates and you will be billed for those higher
costs . An ID card will be mailed to you after enrollment.
Visit www.deltadentalaz.com to ind network
providers, manage your claims, and learn more about
your dental care.
In-Network
Deductible $50 individual
$150 family
Calendar Year Maximum $1,500 per member
Preventive 100% of participating dentist fee
Basic Restorative 80% of participating dentist fee
Major Restorative 50% of participating dentist fee
Orthodontia 50% of participating dentist fee
Orthodontia Eligibility Available to children through age
19; the process must be started
prior to age 17
Please see the plan documents on the NextCare
Intranet beneits page for out-of-network beneits.
Employee Dental Cost Per Pay Period
Employee Only $14 .46
Employee and Spouse $30 .36
Employee and Child(ren) $31 .81
Family $49 .16
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Preventive—oral Examinations, prophylaxis, bitewing NextCare offers dental insurance through Delta
x-rays, x-rays, topical luoride applications, sealants,
and space maintainers Dental of Arizona. Delta Dental has a unique two-
Basic—illings, injections of antibiotic drugs, tiered network of PPO and Premier providers
extractions, emergency palliative treatment, meaning a large network of options for your dental
anesthesia, consultations, repairs, relining and care.
rebasing, endodontics, periodontics, and oral surgery
Major—crowns, inlays, on lays, bridges, and dentures Providers in these networks will never “balance bill”
Balance Billing participants or charge more than the agreed upon
rates for services. Discounts may be deeper in the
Participating providers have agreed to speciic prices for PPO network versus the Premier network. Talk to
procedures in our plan . When you visit non-participating
providers, your cost for services may be more than our your dentist about how they participate.
negotiated rates and you will be billed for those higher
costs . An ID card will be mailed to you after enrollment.
Visit www.deltadentalaz.com to ind network
providers, manage your claims, and learn more about
your dental care.
In-Network
Deductible $50 individual
$150 family
Calendar Year Maximum $1,500 per member
Preventive 100% of participating dentist fee
Basic Restorative 80% of participating dentist fee
Major Restorative 50% of participating dentist fee
Orthodontia 50% of participating dentist fee
Orthodontia Eligibility Available to children through age
19; the process must be started
prior to age 17
Please see the plan documents on the NextCare
Intranet beneits page for out-of-network beneits.
Employee Dental Cost Per Pay Period
Employee Only $14 .46
Employee and Spouse $30 .36
Employee and Child(ren) $31 .81
Family $49 .16
10
