Page 9 - 2015 Enrollment Guide

American Air Filter

Dental Plan

AAF offers standalone dental coverage. You do not have to elect any
other coverage options to take advantage of our dental program. You
have the option to elect four different coverage tiers depending on who
you want to cover for dental insurance.

With our program, if you see a participating provider, preventive
care is covered at 100%. Your basic services are covered at 80% and
your major services are covered at 50% (subject to the annual and/or
lifetime maximum beneit).

Delta Dental
PPO Premier Non-Participating
Calendar Year Deductible
Individual $25 $25 $25
Family $75 $75 $75
Calendar Year $1,500 $1,500 $1,500
Maximum
Coinsurance
Preventive 100% no 100% no 100% of maximum allowance
deductible deductible fee, no deductible
Basic 80% after 80% after 80% of maximum allowance
deductible deductible fee, no deductible
Major 50% after 50% after 50% of maximum allowance
deductible deductible fee, no deductible
Orthodontia
Coinsurance 50% no 50% no 50% of maximum allowance
deductible deductible fee, no deductible $1,000
Lifetime Maximum $1,000 $1,000 $1,000
Visits and Exams
Visit for Oral 100% no 100% no 100% of maximum allowance
examination deductible deductible fee, no deductible
X-rays 100% no 100% no 100% of maximum allowance
deductible deductible fee, no deductible
Endodontics 80% after 80% after 80% of maximum allowance
deductible deductible fee after deductible
Minor Restorations 80% after 80% after 80% of maximum allowance
deductible deductible fee after deductible
Periodontics 80% after 80% after 80% of maximum allowance
deductible deductible fee after deductible
Prosthodontics/Major 50% after 50% after 50% of maximum allowance
Restorations deductible deductible fee after deductible

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