Page 13 - Hussmann- OE Guide
P. 13
Hussmann Corporation
Preventive Dental Care
When it comes to the health of your
Dental Benefits teeth and gums, preventive dental care
In-Network Out-of-Network is smart. Brushing and lossing help to
Annual Deductible None $50 Single/$150 remove plaque from the surfaces and
Waived for orthodontia and Family in between teeth, keeping your teeth
preventive treatment looking and feeling clean. Routine
Maximum Annual Beneit $1,750 Per Person $1,500 Per Person dental exams and regular cleanings
Preventive Services Plan pays 100% Plan pays 100% may help prevent the incidence
Includes exams and cleanings, of reasonable and of higher-cost treatments such as
luoride treatments, x-rays for customary (R&C)
diagnosis, sealants periodontal surgery, root canals,
Basic Services Play pays 80% Plan pays 80% extractions, and illings.
Includes illings and extractions, of R&C after
periodontics, repairs to crowns or deductible
dentures, endodontics, oral surgery
Major Care Services Plan pays 50% Plan pays
Includes crowns, inlays, dentures, 50% of R&C after
dental implants deductible
Orthodontic services Plan pays 50% Plan pays
coverage for dependents to age 19 50% of R&C
Maximum lifetime orthodontia $1,750 Per Person $1,500 Per Person
beneit
Dental Rates as of January 1, 2015
Dental Plan Monthly Employee Contribution
Employee (Ee) $10.12
Ee + Spouse/SSDP $21.25
Ee + Child(ren) $18.21
Family $32.37
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Preventive Dental Care
When it comes to the health of your
Dental Benefits teeth and gums, preventive dental care
In-Network Out-of-Network is smart. Brushing and lossing help to
Annual Deductible None $50 Single/$150 remove plaque from the surfaces and
Waived for orthodontia and Family in between teeth, keeping your teeth
preventive treatment looking and feeling clean. Routine
Maximum Annual Beneit $1,750 Per Person $1,500 Per Person dental exams and regular cleanings
Preventive Services Plan pays 100% Plan pays 100% may help prevent the incidence
Includes exams and cleanings, of reasonable and of higher-cost treatments such as
luoride treatments, x-rays for customary (R&C)
diagnosis, sealants periodontal surgery, root canals,
Basic Services Play pays 80% Plan pays 80% extractions, and illings.
Includes illings and extractions, of R&C after
periodontics, repairs to crowns or deductible
dentures, endodontics, oral surgery
Major Care Services Plan pays 50% Plan pays
Includes crowns, inlays, dentures, 50% of R&C after
dental implants deductible
Orthodontic services Plan pays 50% Plan pays
coverage for dependents to age 19 50% of R&C
Maximum lifetime orthodontia $1,750 Per Person $1,500 Per Person
beneit
Dental Rates as of January 1, 2015
Dental Plan Monthly Employee Contribution
Employee (Ee) $10.12
Ee + Spouse/SSDP $21.25
Ee + Child(ren) $18.21
Family $32.37
13
