Page 11 - Patton19
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2019
Patton Logistics Benefits Enrollment
DENTAL Finding In-Network
We partner with Delta Dental of Tennessee to offer you and your family Providers
members dental insurance. Visit www.DeltaDentalTN.com to ind Remember to visit in-network
in-network providers who participate in the Delta Dental PPO network dentists to receive the deepest
and access a variety of online tools and programs. You have the choice level of discount on your services.
of Delta Dental PPO and Delta Dental Premier providers for in-network To ind a participating in-
services. While the plan will pay for services from non-participating network dentist in your area, go
dentists, you will receive deeper discounts and maximum reimbursement to www.DeltaDentalTN.com or
if you seek services from participating dentists. call 800.223.3104 .
Examples of
Calendar Year Deductible—In-Network
Individual $50 Services
Family $150 Preventive—exams, cleanings,
Calendar Year Maximum luoride, x-rays, and sealants
$1,000 Basic—illings, extractions,
Coinsurance periodontics, repairs, and oral
Preventive 100% no deductible surgery
Basic 50% after deductible Major—crowns, inlays,
Major 50% after deductible dentures, and dental impacts
Orthodontia Not Covered
* Non-participating services reimbursed at the 80th percentile
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in
this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Dental Contributions
Dental
Pre-Tax Weekly Contributions
Basic
Employee $5 .45
Employee/Spouse $10 .75
Employee/Child(ren) $13 .53
Family $21 .21
11
Patton Logistics Benefits Enrollment
DENTAL Finding In-Network
We partner with Delta Dental of Tennessee to offer you and your family Providers
members dental insurance. Visit www.DeltaDentalTN.com to ind Remember to visit in-network
in-network providers who participate in the Delta Dental PPO network dentists to receive the deepest
and access a variety of online tools and programs. You have the choice level of discount on your services.
of Delta Dental PPO and Delta Dental Premier providers for in-network To ind a participating in-
services. While the plan will pay for services from non-participating network dentist in your area, go
dentists, you will receive deeper discounts and maximum reimbursement to www.DeltaDentalTN.com or
if you seek services from participating dentists. call 800.223.3104 .
Examples of
Calendar Year Deductible—In-Network
Individual $50 Services
Family $150 Preventive—exams, cleanings,
Calendar Year Maximum luoride, x-rays, and sealants
$1,000 Basic—illings, extractions,
Coinsurance periodontics, repairs, and oral
Preventive 100% no deductible surgery
Basic 50% after deductible Major—crowns, inlays,
Major 50% after deductible dentures, and dental impacts
Orthodontia Not Covered
* Non-participating services reimbursed at the 80th percentile
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in
this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Dental Contributions
Dental
Pre-Tax Weekly Contributions
Basic
Employee $5 .45
Employee/Spouse $10 .75
Employee/Child(ren) $13 .53
Family $21 .21
11
