Page 19 - Apricity Benefits Guide
P. 19
2020
Apricity Benefits Overview
For Connecticut, Louisiana, and Mississippi: DeltaCare USA is
an open-access plan that features set copays in a convenient
schedule for covered beneits when you visit an in-network
dentist. You may visit any licensed dentist, but to receive in-
network cost protections you must visit an in-network dentist.
With an in-network dentist you’ll be responsible only for your
copay at the time of treatment. Non-Delta Dental dentists may
balance bill you up to their submitted fee. That means you may
be responsible for charges above your ixed copay.
No referral or preauthorization is required for specialty care.
You may change dentists at any time without contacting
Delta Dental.
Delta Dental dentists ile claim forms and accept payment
directly from Delta Dental.
Delta Dental PPO Plan
The Delta Dental PPO Plan features a participating provider
component and a non-participating provider component.
The participating provider component allows you to choose
any dentist from the Delta Dental PPO or Delta Dental Premier
networks while the non-participating provider component allows
you to receive care from any dentist of your choosing.
You will get the most out of your dental beneits and incur
the least out-of-pocket costs by selecting a participating
provider from the Delta Dental networks.
Table of Contents Your Quick Guide to Savings and Group Auto and Home Insurance .33
About Your Beneits Program. . . . . . .2 Spending Accounts .............16 Group Legal Services ............33
Beneits Basics ...................3 Dental Beneits .................18 Employee Assistance Program ....34
Medical/Prescription Drugs Beneits . 6 Dental Plan Summary ............20 Medicare Part D Creditable
Comparing Medical Plan Options ..7 Vision Beneits ..................21 Coverage Notice ...............35
First Stop Health ................11 Voluntary Disability Insurance .....22 Premium Assistance Under Medicaid
Medical Plan Summary ..........12 Life and AD&D Insurance ........25 and the Children’s Health Insurance
Program (CHIP) .................42
Pharmacy Plan Summary .........13 Voluntary Accident Insurance ....29 Contact Information .............46 19
Flexible Spending Accounts ......14 Voluntary Critical Illness Insurance . 31
Apricity Benefits Overview
For Connecticut, Louisiana, and Mississippi: DeltaCare USA is
an open-access plan that features set copays in a convenient
schedule for covered beneits when you visit an in-network
dentist. You may visit any licensed dentist, but to receive in-
network cost protections you must visit an in-network dentist.
With an in-network dentist you’ll be responsible only for your
copay at the time of treatment. Non-Delta Dental dentists may
balance bill you up to their submitted fee. That means you may
be responsible for charges above your ixed copay.
No referral or preauthorization is required for specialty care.
You may change dentists at any time without contacting
Delta Dental.
Delta Dental dentists ile claim forms and accept payment
directly from Delta Dental.
Delta Dental PPO Plan
The Delta Dental PPO Plan features a participating provider
component and a non-participating provider component.
The participating provider component allows you to choose
any dentist from the Delta Dental PPO or Delta Dental Premier
networks while the non-participating provider component allows
you to receive care from any dentist of your choosing.
You will get the most out of your dental beneits and incur
the least out-of-pocket costs by selecting a participating
provider from the Delta Dental networks.
Table of Contents Your Quick Guide to Savings and Group Auto and Home Insurance .33
About Your Beneits Program. . . . . . .2 Spending Accounts .............16 Group Legal Services ............33
Beneits Basics ...................3 Dental Beneits .................18 Employee Assistance Program ....34
Medical/Prescription Drugs Beneits . 6 Dental Plan Summary ............20 Medicare Part D Creditable
Comparing Medical Plan Options ..7 Vision Beneits ..................21 Coverage Notice ...............35
First Stop Health ................11 Voluntary Disability Insurance .....22 Premium Assistance Under Medicaid
Medical Plan Summary ..........12 Life and AD&D Insurance ........25 and the Children’s Health Insurance
Program (CHIP) .................42
Pharmacy Plan Summary .........13 Voluntary Accident Insurance ....29 Contact Information .............46 19
Flexible Spending Accounts ......14 Voluntary Critical Illness Insurance . 31
