Page 11 - Great Circle 2021 Benefits Guide
P. 11
2021
Great Circle Benefits Enrollment
Dental
We partner with Delta Dental to offer you and your eligible family members dental insurance. Dependent
children are eligible to be covered on the dental plan up to age 19 or age 23 if a full-time student and have
provided proof of student status. Visit www.deltadentalmo.com to ind in-network providers and access a
variety of online tools and programs.
In-Network Beneits
Base Option Buy-Up Option Dental coverage provided by
Deductible $25 per individual $25 per individual Delta Dental.
$75 maximum for $75 maximum for
family family
Annual Dependent Eligibility Note
Maximum $1,000 $1,500
Preventive If your child is 19 years of age or older, and is a full
Care Covered 100% Covered at 100% time student (12 hours or more), your child can stay
Basic Care The plan pays 80% The plan pays 80% on the plan if the following information is supplied to
and you pay 20% and you pay 20% FTS@deltadentalmo.com: proof of student status,
Major Care The plan pays 50% The plan pays 50% document showing the name of the school, name of
and you pay 50% and you pay 50%
Orthodontia (dependent beneit applies up to age 19) the student, class, hours for class and total hours.
Coinsurance Not covered Covered at 50%
Lifetime $1,000 per eligible Remember to visit in-network dentists to receive the
Maximum Not covered dependent deepest level of discount on your services.
Beneit Dependent children
Applies To Not applicable up to age 19 To ind a participating in-network dentist in your area go
to www.deltadentalmo.com or call 800.335.8266 .
Dental Contributions Orthodontia Services Note
Base Option Buy-Up Option The lifetime maximum illustrated is diferent from the
Per Pay Period Per Pay Period calendar year maximum. For orthodontia services for
Employee Only $12 .35 $13 .24 children, this limit does not reset each year, this is the
most your plan will cover for your services for the lifetime
Employee + Spouse $25 .81 $27 .67 of your participation in this program.
Employee + Child(ren) $22 .31 $28 .18
Employee + Family $32 .84 $39 .48 Examples of Services
Preventive—exams, cleanings, luoride, x-rays,
and sealants
Basic—illings, simple extractions, and
stainless crowns
Major—periodontics, repairs, and oral surgery
Implants are not a covered service under the
dental plan.
11
Great Circle Benefits Enrollment
Dental
We partner with Delta Dental to offer you and your eligible family members dental insurance. Dependent
children are eligible to be covered on the dental plan up to age 19 or age 23 if a full-time student and have
provided proof of student status. Visit www.deltadentalmo.com to ind in-network providers and access a
variety of online tools and programs.
In-Network Beneits
Base Option Buy-Up Option Dental coverage provided by
Deductible $25 per individual $25 per individual Delta Dental.
$75 maximum for $75 maximum for
family family
Annual Dependent Eligibility Note
Maximum $1,000 $1,500
Preventive If your child is 19 years of age or older, and is a full
Care Covered 100% Covered at 100% time student (12 hours or more), your child can stay
Basic Care The plan pays 80% The plan pays 80% on the plan if the following information is supplied to
and you pay 20% and you pay 20% FTS@deltadentalmo.com: proof of student status,
Major Care The plan pays 50% The plan pays 50% document showing the name of the school, name of
and you pay 50% and you pay 50%
Orthodontia (dependent beneit applies up to age 19) the student, class, hours for class and total hours.
Coinsurance Not covered Covered at 50%
Lifetime $1,000 per eligible Remember to visit in-network dentists to receive the
Maximum Not covered dependent deepest level of discount on your services.
Beneit Dependent children
Applies To Not applicable up to age 19 To ind a participating in-network dentist in your area go
to www.deltadentalmo.com or call 800.335.8266 .
Dental Contributions Orthodontia Services Note
Base Option Buy-Up Option The lifetime maximum illustrated is diferent from the
Per Pay Period Per Pay Period calendar year maximum. For orthodontia services for
Employee Only $12 .35 $13 .24 children, this limit does not reset each year, this is the
most your plan will cover for your services for the lifetime
Employee + Spouse $25 .81 $27 .67 of your participation in this program.
Employee + Child(ren) $22 .31 $28 .18
Employee + Family $32 .84 $39 .48 Examples of Services
Preventive—exams, cleanings, luoride, x-rays,
and sealants
Basic—illings, simple extractions, and
stainless crowns
Major—periodontics, repairs, and oral surgery
Implants are not a covered service under the
dental plan.
11
