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Dental
Dental Plan Options—Delta Dental
First Bank offers dental coverage through the Delta Dental PPO
Network, the largest dental network in the US. You may choose to
participate in one of two plans called “Option A” and “Option B”. The
Option A plan provides a higher level of beneit and requires a higher per
pay period employee contribution. The Option B plan carries a lower per
pay period cost but provides coverage on basic and restorative services
only. Because this is a PPO plan, participants may obtain services outside
the Delta Dental PPO network; however, copayments outside the PPO
network will be greater. Services obtained from providers in the Delta
Dental Premier network who are not members of the Delta Dental PPO
network are considered out-of-network services in this plan.
Dental services are covered as indicated in the following schedule.
Out-of-
Covered Beneits—Option A In-Network Network
A. Diagnostic and preventive services 100% 100%
B. Basic and restorative services 85% 80%
C. Major services 60% 50%
D. Orthodontia (children to age 19) 40% 40%
Individual deductible (applies to B and C above only) $50 $50
Family deductible (applies to B and C above only) $150 $150
Maximum beneit per person per year (excl. ortho) $1,500 $1,500
Maximum lifetime orthodontia beneit (per child) $1,000 $1,000
Covered Beneits—Option B In-Network Out-of-
Network
A. Diagnostic and preventive services 100% 100%
B. Basic and restorative services 80% 50%
C. Major services N/A N/A
D. Orthodontia (children to age 19) N/A N/A
Individual deductible (applies to B above only) $50 $50
Family deductible (applies to B above only) $150 $150
Maximum beneit per person per year $1,000 $1,000
2016 Open Enrollment
Dental
Dental Plan Options—Delta Dental
First Bank offers dental coverage through the Delta Dental PPO
Network, the largest dental network in the US. You may choose to
participate in one of two plans called “Option A” and “Option B”. The
Option A plan provides a higher level of beneit and requires a higher per
pay period employee contribution. The Option B plan carries a lower per
pay period cost but provides coverage on basic and restorative services
only. Because this is a PPO plan, participants may obtain services outside
the Delta Dental PPO network; however, copayments outside the PPO
network will be greater. Services obtained from providers in the Delta
Dental Premier network who are not members of the Delta Dental PPO
network are considered out-of-network services in this plan.
Dental services are covered as indicated in the following schedule.
Out-of-
Covered Beneits—Option A In-Network Network
A. Diagnostic and preventive services 100% 100%
B. Basic and restorative services 85% 80%
C. Major services 60% 50%
D. Orthodontia (children to age 19) 40% 40%
Individual deductible (applies to B and C above only) $50 $50
Family deductible (applies to B and C above only) $150 $150
Maximum beneit per person per year (excl. ortho) $1,500 $1,500
Maximum lifetime orthodontia beneit (per child) $1,000 $1,000
Covered Beneits—Option B In-Network Out-of-
Network
A. Diagnostic and preventive services 100% 100%
B. Basic and restorative services 80% 50%
C. Major services N/A N/A
D. Orthodontia (children to age 19) N/A N/A
Individual deductible (applies to B above only) $50 $50
Family deductible (applies to B above only) $150 $150
Maximum beneit per person per year $1,000 $1,000
2016 Open Enrollment
