Page 14 - Benefits Guide
P. 14
Find an In-Network Dental Coverage
Provider Access to good oral healthcare can help keep your overall health costs
Remember to visit in-network down. Regular oral health exams can help detect signiicant medical
(Delta Dental PPO or Delta Premier) conditions before they become serious. Dental professionals performing
dentists to receive the deepest level checkups can spot symptoms which could indicate serious health
of discount on your services . Delta
PPO dentists have agreed to provide conditions. For these reasons, and many others, we offer dental insurance
discounts from 20% to 30%; Delta through Delta Dental of Tennessee to our employees. Delta Dental offers
Premier from 5% to 10% . Out-of- a comprehensive network within and outside of Tennessee; 4 out of 5
network dentists will be reimbursed dentists are in the Delta Dental PPO.
at Delta Dental’s maximum
allowable charge which is equivalent Delta PPO and
to the 51st percentile of usual and Delta Dental of Tennessee Delta Premier Out-of-Network
customary fees and may balance- Calendar Year Deductible
bill you for the difference between Individual $50 $50
billed and allowed charges . Family $150 $150
To ind a participating in-network Calendar Year Maximum
dentist in your area go to $1,250 $1,250
deltadentaltn.com . Coinsurance
Preventive 100% no deductible 100% no deductible*
Orthodontia Services Basic 80% after deductible 80% after deductible*
Note
Major 50% after deductible 50% after deductible*
The lifetime maximum illustrated Orthodontia
is different from the calendar year Coinsurance 50% after deductible 50% after deductible
maximum . For orthodontia services,
this limit does not reset each year, Lifetime Maximum $1,000 $1,000
this is the most your plan will cover Beneit Applies to Members up to age 19 Members up to age 19
for your dependent child’s services
for the lifetime of your participation This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in
in this program . this guide and what is communicated in your SPD, the terms of your SPD will prevail .
Examples of Services Pre-Tax Bi-Weekly Contributions
Preventive—exams, cleanings, Employee $6 .99
luoride, x-rays, sealants Employee and Spouse $14 .55
Employee and Child(ren) $15 .60
Basic—illings, extractions, Family
periodontics, repairs, and oral $25 .81
surgery * See out-of-network reimbursements information provided in the column on the left .
Major—crowns, inlays,
dentures, dental impacts
14 2017–18 Benefits Enrollment
Provider Access to good oral healthcare can help keep your overall health costs
Remember to visit in-network down. Regular oral health exams can help detect signiicant medical
(Delta Dental PPO or Delta Premier) conditions before they become serious. Dental professionals performing
dentists to receive the deepest level checkups can spot symptoms which could indicate serious health
of discount on your services . Delta
PPO dentists have agreed to provide conditions. For these reasons, and many others, we offer dental insurance
discounts from 20% to 30%; Delta through Delta Dental of Tennessee to our employees. Delta Dental offers
Premier from 5% to 10% . Out-of- a comprehensive network within and outside of Tennessee; 4 out of 5
network dentists will be reimbursed dentists are in the Delta Dental PPO.
at Delta Dental’s maximum
allowable charge which is equivalent Delta PPO and
to the 51st percentile of usual and Delta Dental of Tennessee Delta Premier Out-of-Network
customary fees and may balance- Calendar Year Deductible
bill you for the difference between Individual $50 $50
billed and allowed charges . Family $150 $150
To ind a participating in-network Calendar Year Maximum
dentist in your area go to $1,250 $1,250
deltadentaltn.com . Coinsurance
Preventive 100% no deductible 100% no deductible*
Orthodontia Services Basic 80% after deductible 80% after deductible*
Note
Major 50% after deductible 50% after deductible*
The lifetime maximum illustrated Orthodontia
is different from the calendar year Coinsurance 50% after deductible 50% after deductible
maximum . For orthodontia services,
this limit does not reset each year, Lifetime Maximum $1,000 $1,000
this is the most your plan will cover Beneit Applies to Members up to age 19 Members up to age 19
for your dependent child’s services
for the lifetime of your participation This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in
in this program . this guide and what is communicated in your SPD, the terms of your SPD will prevail .
Examples of Services Pre-Tax Bi-Weekly Contributions
Preventive—exams, cleanings, Employee $6 .99
luoride, x-rays, sealants Employee and Spouse $14 .55
Employee and Child(ren) $15 .60
Basic—illings, extractions, Family
periodontics, repairs, and oral $25 .81
surgery * See out-of-network reimbursements information provided in the column on the left .
Major—crowns, inlays,
dentures, dental impacts
14 2017–18 Benefits Enrollment
