Page 19 - CPS Benefits Guide
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Delta Dental
Dental coverage is offered through Delta Dental of Tennessee to Semi-Monthly Base Buy-
all eligible employees, their spouses, and their dependent children. Plan Up
Maintaining healthy teeth and gums and seeking professional treatment Employee $5 .52 $10 .21
when dental problems arise is important to your overall health. Employee and $11 .35 $20 .94
spouse
Employees and their families should maintain good dental habits and seek Employee and $11 .13 $22 .80
professional dental care. Visit deltadentaltn.com or call 800.223.3104. child(ren)
Employee and $19 .40 $38 .88
family
Base Plan Buy-Up Plan
Premier and
Premier and
PPO Out-of-Network PPO Out-of-Network
Calendar Year Deductible
Individual $50 $50 $50 $50
Family $150 $150 $150 $150
Calendar Year Maximum
$1,500 $1,500 $2,000 $2,000
Coinsurance
Preventive 100% no ded . 80% no ded . 100% no ded . 100% no ded .
Basic 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Major 50% after ded . 50% after ded . 50% after ded . 50% after ded .
Orthodontia
Deductible Not covered Not covered $0 $0
Coinsurance Not covered Not covered 50% after ded . 50% after ded .
Lifetime Maximum Not covered Not covered $1,000 $1,000
Beneit Applies to Not covered Not covered Children under 19 Children under 19
Diagnostic and Preventive Services
Diagnostic and Preventive Services 100% no ded . 80% no ded . 100% no ded . 100% no ded .
Space Maintainers 100% no ded . 80% no ded . 100% no ded . 100% no ded .
X-rays
Bite Wing X-Rays 100% no ded . 80% no ded . 100% no ded . 100% no ded .
Full Mouth X-Rays 100% no ded . 80% no ded . 100% no ded . 100% no ded .
Basic Services
Sealants 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Oral Surgery: Simple Extractions 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Restorative: Amalgam, Synthetic Porcelain 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Plastic Restorations (illings) 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Relinings and Rebasings of Existing 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Removable Dentures
Endodontics 50% after ded . 50% after ded . 50% after ded . 50% after ded .
Periodontics 50% after ded . 50% after ded . 50% after ded . 50% after ded .
Prosthodontics/Major Restorations
Major Services 50% after ded . 50% after ded . 50% after ded . 50% after ded .
Crowns, Jackets, and Cast Restoration 50% after ded . 50% after ded . 50% after ded . 50% after ded .
Prosthodontics (ixed bridges, partial/ 50% after ded . 50% after ded . 50% after ded . 50% after ded .
complete dentures)
Comprehensive Pharmacy Services 19
Dental coverage is offered through Delta Dental of Tennessee to Semi-Monthly Base Buy-
all eligible employees, their spouses, and their dependent children. Plan Up
Maintaining healthy teeth and gums and seeking professional treatment Employee $5 .52 $10 .21
when dental problems arise is important to your overall health. Employee and $11 .35 $20 .94
spouse
Employees and their families should maintain good dental habits and seek Employee and $11 .13 $22 .80
professional dental care. Visit deltadentaltn.com or call 800.223.3104. child(ren)
Employee and $19 .40 $38 .88
family
Base Plan Buy-Up Plan
Premier and
Premier and
PPO Out-of-Network PPO Out-of-Network
Calendar Year Deductible
Individual $50 $50 $50 $50
Family $150 $150 $150 $150
Calendar Year Maximum
$1,500 $1,500 $2,000 $2,000
Coinsurance
Preventive 100% no ded . 80% no ded . 100% no ded . 100% no ded .
Basic 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Major 50% after ded . 50% after ded . 50% after ded . 50% after ded .
Orthodontia
Deductible Not covered Not covered $0 $0
Coinsurance Not covered Not covered 50% after ded . 50% after ded .
Lifetime Maximum Not covered Not covered $1,000 $1,000
Beneit Applies to Not covered Not covered Children under 19 Children under 19
Diagnostic and Preventive Services
Diagnostic and Preventive Services 100% no ded . 80% no ded . 100% no ded . 100% no ded .
Space Maintainers 100% no ded . 80% no ded . 100% no ded . 100% no ded .
X-rays
Bite Wing X-Rays 100% no ded . 80% no ded . 100% no ded . 100% no ded .
Full Mouth X-Rays 100% no ded . 80% no ded . 100% no ded . 100% no ded .
Basic Services
Sealants 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Oral Surgery: Simple Extractions 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Restorative: Amalgam, Synthetic Porcelain 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Plastic Restorations (illings) 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Relinings and Rebasings of Existing 80% after ded . 60% after ded . 80% after ded . 80% after ded .
Removable Dentures
Endodontics 50% after ded . 50% after ded . 50% after ded . 50% after ded .
Periodontics 50% after ded . 50% after ded . 50% after ded . 50% after ded .
Prosthodontics/Major Restorations
Major Services 50% after ded . 50% after ded . 50% after ded . 50% after ded .
Crowns, Jackets, and Cast Restoration 50% after ded . 50% after ded . 50% after ded . 50% after ded .
Prosthodontics (ixed bridges, partial/ 50% after ded . 50% after ded . 50% after ded . 50% after ded .
complete dentures)
Comprehensive Pharmacy Services 19
