Page 19 - Busey 2021 Annual Benefits Enrollment
P. 19
First Busey Corporation Benefits Guide
Dental
We partner with Guardian to offer you In-Network Out-of-Network
comprehensive dental coverage. Our dental plan Calendar Year Deductible
makes dental care more affordable for associates Individual $50 $50
and their families. Keep in mind, the information in Family $150 $150
the chart provided is a summary only. Please refer Coinsurance 100% 100%
Preventive
to your Certiicate of Coverage (COC) for complete Basic 80% 80%
details OTL. Major 50% 50%
Calendar Year Maximum
Visit www.guardiananytime.com. $1,250 $1,250
Orthodontia
Coinsurance 50% 50%
Guardian ofers a maximum rollover feature. Here’s how Lifetime Maximum $1,500 $1,500
it works: Beneit Applies to Children under age 20 Children under age 20
Visits and Exams
If you incur $600 or less of dental claims during the Visit for Oral Once every 6 months Once every 6 months
Examination
plan year, you are allowed a maximum rollover amount Prophylaxis, Once every 6 months Once every 6 months
of $300 to be added to your plan maximum for future Including Scaling
years. As an added bonus, if you saw only in-network and Polishing
providers during the plan year, you will receive an Fluoride Once every 6 months Once every 6 months
additional $150 towards your annual maximum amount. Children under age 19 Children under age 19
Sealants Once every 6 months Once every 6 months
Children under age 19 Children under age 19
X-Rays
To Find a Dental Provider Bitewing X-Rays 2 per beneit year 2 per beneit year
1. Go to www.guardiananytime.com Full Mouth X-Rays Once every 60 months Once every 60 months
Endodontics
2. Hover over MyAccount/Login Pulpotomy Covered at 80% Covered at 80%
3. Select “Find a Provider” (top, right) Apicoectomy Covered at 80% Covered at 80%
Guardian ofers a maximum rollover feature. Here’s how it
4. Select “PPO” as plan type and enter ZIP Code, then Minor Restorations Covered at 80% Covered at 80%
Amalgam (silver)
press “Search” Fillings works:
Composite Fillings Covered at 80% Covered at 80%
If you incur $600 or less of dental claims during the plan
(anterior teeth
Benefit Compensation only) year, you are allowed a maximum rollover amount of $300
to be added to your plan maximum for future years. As an
Stainless Steel
Covered at 80%
Covered at 80%
added bonus, if you saw only in-network providers during
Bi-Weekly Rates Beneit Levels Beneit Levels Crowns Covered at 80% Covered at 80%
Uncomplicated
6–8
2–5
the plan year, you will receive an additional $150 towards
Associate Only $9.90 $11.42 Extractions
your annual maximum amount.
Associate + Spouse $22.84 $25.88 Surgical Removal Covered at 80% Covered at 80%
of Erupted Tooth
Associate + Child(ren) $28.39 $32.17 Inlays Covered at 50% Covered at 50%
Family $46.41 $52.60 Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%
Full and Partial Covered at 50% Covered at 50%
Dentures
Denture Repairs Covered at 50% Covered at 50%
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Dental
We partner with Guardian to offer you In-Network Out-of-Network
comprehensive dental coverage. Our dental plan Calendar Year Deductible
makes dental care more affordable for associates Individual $50 $50
and their families. Keep in mind, the information in Family $150 $150
the chart provided is a summary only. Please refer Coinsurance 100% 100%
Preventive
to your Certiicate of Coverage (COC) for complete Basic 80% 80%
details OTL. Major 50% 50%
Calendar Year Maximum
Visit www.guardiananytime.com. $1,250 $1,250
Orthodontia
Coinsurance 50% 50%
Guardian ofers a maximum rollover feature. Here’s how Lifetime Maximum $1,500 $1,500
it works: Beneit Applies to Children under age 20 Children under age 20
Visits and Exams
If you incur $600 or less of dental claims during the Visit for Oral Once every 6 months Once every 6 months
Examination
plan year, you are allowed a maximum rollover amount Prophylaxis, Once every 6 months Once every 6 months
of $300 to be added to your plan maximum for future Including Scaling
years. As an added bonus, if you saw only in-network and Polishing
providers during the plan year, you will receive an Fluoride Once every 6 months Once every 6 months
additional $150 towards your annual maximum amount. Children under age 19 Children under age 19
Sealants Once every 6 months Once every 6 months
Children under age 19 Children under age 19
X-Rays
To Find a Dental Provider Bitewing X-Rays 2 per beneit year 2 per beneit year
1. Go to www.guardiananytime.com Full Mouth X-Rays Once every 60 months Once every 60 months
Endodontics
2. Hover over MyAccount/Login Pulpotomy Covered at 80% Covered at 80%
3. Select “Find a Provider” (top, right) Apicoectomy Covered at 80% Covered at 80%
Guardian ofers a maximum rollover feature. Here’s how it
4. Select “PPO” as plan type and enter ZIP Code, then Minor Restorations Covered at 80% Covered at 80%
Amalgam (silver)
press “Search” Fillings works:
Composite Fillings Covered at 80% Covered at 80%
If you incur $600 or less of dental claims during the plan
(anterior teeth
Benefit Compensation only) year, you are allowed a maximum rollover amount of $300
to be added to your plan maximum for future years. As an
Stainless Steel
Covered at 80%
Covered at 80%
added bonus, if you saw only in-network providers during
Bi-Weekly Rates Beneit Levels Beneit Levels Crowns Covered at 80% Covered at 80%
Uncomplicated
6–8
2–5
the plan year, you will receive an additional $150 towards
Associate Only $9.90 $11.42 Extractions
your annual maximum amount.
Associate + Spouse $22.84 $25.88 Surgical Removal Covered at 80% Covered at 80%
of Erupted Tooth
Associate + Child(ren) $28.39 $32.17 Inlays Covered at 50% Covered at 50%
Family $46.41 $52.60 Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%
Full and Partial Covered at 50% Covered at 50%
Dentures
Denture Repairs Covered at 50% Covered at 50%
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