Page 20 - Apricity Benefits Guide
P. 20
2020
Apricity Benefits Overview
DENTAL PLAN SUMMARY
This chart summarizes what you pay under the Delta Dental PPO Plan. For more detailed
information, please refer to your Summary Plan Description.
Delta Dental PPO Plan
Beneit Description Participating Providers
Delta Dental PPO 1 Delta Dental Premier 2 Non-Participating Providers 3
Calendar Year Deductible (excludes Diagnostic and Preventive Services and Orthodontics)
Individual $50 $50 $50
Family $150 $150 $150
Calendar Year Maximum
$1,000 per person
Dental Services
Diagnostic and Preventive Covered 100% Covered 100% Covered 100%
Services deductible waived deductible waived deductible waived
Basic Restorative Services 20% after deductible 20% after deductible 20% after deductible
Major Restorative Services 50% after deductible 50% after deductible 50% after deductible
Oral Surgery, Endodontics, 20% after deductible 20% after deductible 20% after deductible
and Periodontics
Prosthodontics 50% after deductible 50% after deductible 50% after deductible
Orthodontia (Children to age 19)
Orthodontics Covered 50% Covered 50% Covered 50%
Orthodontia Lifetime $1,000 $1,000 $1,000
Maximum
1 Delta Dental PPO dentists are paid at the Delta Dental PPO Maximum Plan Allowance.
2 Delta Dental Premier dentists are paid the Delta Dental Premier Maximum Plan Allowance. The dentist can bill you for the difference
between the Delta Dental PPO Maximum Plan Allowance and the Delta Dental Premier Maximum Plan Allowance.
3 For eligible services provided by a non-participating dentist, Delta reimburses you up to the Delta Dental PPO Maximum Plan
Allowance. The non-participating dentist can then bill you for the difference between Delta’s reimbursement and the dentist’s
actual charge.
Dental—Employee Contributions Per Pay Period
COVERAGE DeltaCare USA HMO Delta Dental PPO
Employee Only $6.63 $12.66
Employee + Spouse $11.61 $20.01
Employee + Child $11.61 $20.01
Employee + Child(ren) $17.17 $34.78
Family $17.17 $34.78
This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including beneits
required by your state, see your employer’s insurance certiicate or Summary Plan Description for the oficial plan documents. If there
are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
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 20
Flexible Spending Accounts ......14 Voluntary Critical Illness Insurance . 31
Apricity Benefits Overview
DENTAL PLAN SUMMARY
This chart summarizes what you pay under the Delta Dental PPO Plan. For more detailed
information, please refer to your Summary Plan Description.
Delta Dental PPO Plan
Beneit Description Participating Providers
Delta Dental PPO 1 Delta Dental Premier 2 Non-Participating Providers 3
Calendar Year Deductible (excludes Diagnostic and Preventive Services and Orthodontics)
Individual $50 $50 $50
Family $150 $150 $150
Calendar Year Maximum
$1,000 per person
Dental Services
Diagnostic and Preventive Covered 100% Covered 100% Covered 100%
Services deductible waived deductible waived deductible waived
Basic Restorative Services 20% after deductible 20% after deductible 20% after deductible
Major Restorative Services 50% after deductible 50% after deductible 50% after deductible
Oral Surgery, Endodontics, 20% after deductible 20% after deductible 20% after deductible
and Periodontics
Prosthodontics 50% after deductible 50% after deductible 50% after deductible
Orthodontia (Children to age 19)
Orthodontics Covered 50% Covered 50% Covered 50%
Orthodontia Lifetime $1,000 $1,000 $1,000
Maximum
1 Delta Dental PPO dentists are paid at the Delta Dental PPO Maximum Plan Allowance.
2 Delta Dental Premier dentists are paid the Delta Dental Premier Maximum Plan Allowance. The dentist can bill you for the difference
between the Delta Dental PPO Maximum Plan Allowance and the Delta Dental Premier Maximum Plan Allowance.
3 For eligible services provided by a non-participating dentist, Delta reimburses you up to the Delta Dental PPO Maximum Plan
Allowance. The non-participating dentist can then bill you for the difference between Delta’s reimbursement and the dentist’s
actual charge.
Dental—Employee Contributions Per Pay Period
COVERAGE DeltaCare USA HMO Delta Dental PPO
Employee Only $6.63 $12.66
Employee + Spouse $11.61 $20.01
Employee + Child $11.61 $20.01
Employee + Child(ren) $17.17 $34.78
Family $17.17 $34.78
This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including beneits
required by your state, see your employer’s insurance certiicate or Summary Plan Description for the oficial plan documents. If there
are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
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 20
Flexible Spending Accounts ......14 Voluntary Critical Illness Insurance . 31
