Page 11 - HIMSS 2021 Annual Benefits Enrollment
P. 11
DENTAL PLAN
Your dental health is an important part of your overall wellness. The dental plan through Delta Dental of
Illinois covers preventive care (including regular checkups) as well as fillings, bridges, crowns, and other
dental services.
DELTA PPO NETWORK DELTA PREMIER NETWORK /
OUT-OF-NETWORK**
ANNUAL DEDUCTIBLE
Individual $50 $50
Family $150 $150
ANNUAL MAXIMUM
Per Individual $1,500
YOU PAY
DIAGNOSTIC AND PREVENTIVE
Cleanings, Fluoride Treatments,
Sealants and X-rays $0 $0
BASIC SERVICES
Fillings, Periodontics, Scaling and
Root Planning and Oral Surgery 10%* 20%*
MAJOR SERVICES
Crowns, Bridges, Full and
Partial Dentures 40%* 50%*
ORTHODONTIA (CHILD ONLY UP TO AGE 19)
50%*; $1,500 lifetime maximum
*After deductible is met.
**Delta Premier Network claims are based on an agreed upon fee schedule. Out-of-network claim payment will be based on usual & customary charges.
11
Your dental health is an important part of your overall wellness. The dental plan through Delta Dental of
Illinois covers preventive care (including regular checkups) as well as fillings, bridges, crowns, and other
dental services.
DELTA PPO NETWORK DELTA PREMIER NETWORK /
OUT-OF-NETWORK**
ANNUAL DEDUCTIBLE
Individual $50 $50
Family $150 $150
ANNUAL MAXIMUM
Per Individual $1,500
YOU PAY
DIAGNOSTIC AND PREVENTIVE
Cleanings, Fluoride Treatments,
Sealants and X-rays $0 $0
BASIC SERVICES
Fillings, Periodontics, Scaling and
Root Planning and Oral Surgery 10%* 20%*
MAJOR SERVICES
Crowns, Bridges, Full and
Partial Dentures 40%* 50%*
ORTHODONTIA (CHILD ONLY UP TO AGE 19)
50%*; $1,500 lifetime maximum
*After deductible is met.
**Delta Premier Network claims are based on an agreed upon fee schedule. Out-of-network claim payment will be based on usual & customary charges.
11
