Page 17 - 2015 First Busey Enrollment Guide
P. 17
First Busey Corporation
Dental
PPO/Premier Dental
In-Network Out-of-Network
Calendar Year Deductible Our dental plan makes
Individual $50 $50 dental care more affordable
Family $150 $150 for associates and their
Calendar Year Maximum
Coinsurance families. We partner with
Preventive 100% 100% Delta Dental of IL to offer
Basic 80% 80% you comprehensive dental
Major 50% 50%
Orthodontia coverage options. Keep in
Coinsurance 50% 50% mind, the information in the
Lifetime Maximum $1,000 $1,000 chart provided is a summary
Beneit applies to Children under age 19 Children under age 19
Visits and Exams only. Please refer to your
Visit for oral examination 2 per beneit year 2 per beneit year Certiicate of Coverage
Prophylaxis, including scaling 2 per beneit year 2 per beneit year
and polishing (COC) for complete details
Fluoride Once per beneit year Once per beneit year on OTL.
Children under age 19 Children under age 19
Sealants Under age 16 Under age 16
X-rays Delta Dental of Illinois
Bitewing x-rays 2 per beneit year 2 per beneit year offers two networks: a
Full mouth x-rays Once every three years Once every three years Premier network and a
Endodontics
Pulpotomy Covered at 80% Covered at 80% PPO network. While the
Apicoectomy Covered at 80% Covered at 80% Premier network offers
Minor Restorations deep discounts, you will
Amalgam (silver) illings Covered at 80% Covered at 80%
Composite illings (anterior Covered at 80% Covered at 80% ind the greatest discounts
teeth only) with providers who are
Stainless steel crowns Covered at 50% Covered at 50% under the PPO network.
Uncomplicated extractions Covered at 80% Covered at 80%
Surgical removal of erupted Covered at 80% Covered at 80% Most providers in the PPO
tooth network are also in the
Inlays Covered at 50% Covered at 50%
Onlays Covered at 50% Covered at 50% Premier network because
Crowns Covered at 50% Covered at 50% the Premier network is a
Full & partial dentures Covered at 50% Covered at 50% larger network. Please visit
Denture repairs Covered at 50% Covered at 50%
www.deltadentalil.com.
Benefit Compensation
Bi-weekly Rates < $92,500 ≥ $92,500
Associate Only $9.42 $10.76
Associate + Spouse $21.53 $24.22
Associate + Child(ren) $26.76 $30.10
Family $43.74 $49.21
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Dental
PPO/Premier Dental
In-Network Out-of-Network
Calendar Year Deductible Our dental plan makes
Individual $50 $50 dental care more affordable
Family $150 $150 for associates and their
Calendar Year Maximum
Coinsurance families. We partner with
Preventive 100% 100% Delta Dental of IL to offer
Basic 80% 80% you comprehensive dental
Major 50% 50%
Orthodontia coverage options. Keep in
Coinsurance 50% 50% mind, the information in the
Lifetime Maximum $1,000 $1,000 chart provided is a summary
Beneit applies to Children under age 19 Children under age 19
Visits and Exams only. Please refer to your
Visit for oral examination 2 per beneit year 2 per beneit year Certiicate of Coverage
Prophylaxis, including scaling 2 per beneit year 2 per beneit year
and polishing (COC) for complete details
Fluoride Once per beneit year Once per beneit year on OTL.
Children under age 19 Children under age 19
Sealants Under age 16 Under age 16
X-rays Delta Dental of Illinois
Bitewing x-rays 2 per beneit year 2 per beneit year offers two networks: a
Full mouth x-rays Once every three years Once every three years Premier network and a
Endodontics
Pulpotomy Covered at 80% Covered at 80% PPO network. While the
Apicoectomy Covered at 80% Covered at 80% Premier network offers
Minor Restorations deep discounts, you will
Amalgam (silver) illings Covered at 80% Covered at 80%
Composite illings (anterior Covered at 80% Covered at 80% ind the greatest discounts
teeth only) with providers who are
Stainless steel crowns Covered at 50% Covered at 50% under the PPO network.
Uncomplicated extractions Covered at 80% Covered at 80%
Surgical removal of erupted Covered at 80% Covered at 80% Most providers in the PPO
tooth network are also in the
Inlays Covered at 50% Covered at 50%
Onlays Covered at 50% Covered at 50% Premier network because
Crowns Covered at 50% Covered at 50% the Premier network is a
Full & partial dentures Covered at 50% Covered at 50% larger network. Please visit
Denture repairs Covered at 50% Covered at 50%
www.deltadentalil.com.
Benefit Compensation
Bi-weekly Rates < $92,500 ≥ $92,500
Associate Only $9.42 $10.76
Associate + Spouse $21.53 $24.22
Associate + Child(ren) $26.76 $30.10
Family $43.74 $49.21
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