Page 8 - 2019 NextCare
P. 8
Example Services Dental
X Preventive—oral
Examinations, prophylaxis, NextCare offers dental insurance through Delta Dental of Arizona. Delta
bitewing x-rays, x-rays, topical Dental has a unique two-tiered network of PPO and Premier providers
fluoride applications, sealants, meaning a large network of options for your dental care.
and space maintainers
Providers in these networks will never “balance bill” participants or
X Basic—fillings, injections of
antibiotic drugs, extractions, charge more than the agreed upon rates for services. Discounts may be
emergency palliative deeper in the PPO network versus the Premier network. Talk to your
treatment, anesthesia, dentist about how they participate.
consultations, repairs, relining
and rebasing, endodontics, An ID card will be mailed to you after enrollment. Visit
periodontics, and oral surgery www.deltadentalaz.com to ind network providers, manage your claims,
X Major—crowns, inlays, on lays, and learn more about your dental care.
bridges, and dentures
In-Network
Balance Billing Deductible $50 individual
$150 family
Participating providers have
agreed to specific prices for Calendar Year Maximum $1,500 per member
procedures in our plan . When you Preventive 100% of participating dentist fee
visit non-participating providers Basic Restorative 80% of participating dentist fee
your cost for services may be Major Restorative 50% of participating dentist fee
more than our negotiated rates Orthodontia 50% of participating dentist fee
and you will be billed for those Orthodontia Eligibility Available to children through age 19;
higher costs . the process must be started prior
to age 17
Please see the plan documents on the NextCare Intranet beneits page for
out-of-network beneits.
Employee Dental Cost Per Pay Period
Employee Only $14 .46
Employee and Spouse $30 .36
Employee and Child(ren) $31 .81
Family $49 .16
8 2019 Benefits Guide
X Preventive—oral
Examinations, prophylaxis, NextCare offers dental insurance through Delta Dental of Arizona. Delta
bitewing x-rays, x-rays, topical Dental has a unique two-tiered network of PPO and Premier providers
fluoride applications, sealants, meaning a large network of options for your dental care.
and space maintainers
Providers in these networks will never “balance bill” participants or
X Basic—fillings, injections of
antibiotic drugs, extractions, charge more than the agreed upon rates for services. Discounts may be
emergency palliative deeper in the PPO network versus the Premier network. Talk to your
treatment, anesthesia, dentist about how they participate.
consultations, repairs, relining
and rebasing, endodontics, An ID card will be mailed to you after enrollment. Visit
periodontics, and oral surgery www.deltadentalaz.com to ind network providers, manage your claims,
X Major—crowns, inlays, on lays, and learn more about your dental care.
bridges, and dentures
In-Network
Balance Billing Deductible $50 individual
$150 family
Participating providers have
agreed to specific prices for Calendar Year Maximum $1,500 per member
procedures in our plan . When you Preventive 100% of participating dentist fee
visit non-participating providers Basic Restorative 80% of participating dentist fee
your cost for services may be Major Restorative 50% of participating dentist fee
more than our negotiated rates Orthodontia 50% of participating dentist fee
and you will be billed for those Orthodontia Eligibility Available to children through age 19;
higher costs . the process must be started prior
to age 17
Please see the plan documents on the NextCare Intranet beneits page for
out-of-network beneits.
Employee Dental Cost Per Pay Period
Employee Only $14 .46
Employee and Spouse $30 .36
Employee and Child(ren) $31 .81
Family $49 .16
8 2019 Benefits Guide
