Page 11 - Great Circle 2022 Benefits Guide
P. 11
2022
Benefits Guide
Dental
We partner with Delta Dental to ofer 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 Dental coverage provided
Base Option Buy-Up Option
$25 per individual $25 per individual by Delta Dental.
Deductible $75 maximum for $75 maximum for
family family
Annual Dependent Eligibility Note
Maximum $1,000 $1,500
Preventive Care Covered 100% Covered at 100% If your child is 19 years of age or older, and is a full
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
and you pay 20%
and you pay 20%
Major Care The plan pays 50% The plan pays 50% to FTS@deltadentalmo.com: proof of student
and you pay 50%
and you pay 50%
status, document showing the name of the school,
Orthodontia (dependent beneit applies up to age 19) name of the student, class, hours for class and
Coinsurance Not covered Covered at 50% total hours.
Lifetime Not covered $1,000 per eligible
Maximum dependent
Beneit Applies Not applicable Dependent children Remember to visit in-network dentists to receive the
To up to age 19 deepest level of discount on your services.
To ind a participating in-network dentist in your area go to
Dental Contributions www.deltadentalmo.com or call 800.335.8266.
Base Option Buy-Up Option Orthodontia Services Note
Per Pay Period Per Pay Period
Employee Only $11.89 $12.74 The lifetime maximum illustrated is diferent from the
calendar year maximum. For orthodontia services for
Employee + Spouse $24.84 $26.62 children, this limit does not reset each year, this is the most
Employee + Child(ren) $21.47 $27.12 your plan will cover for your services for the lifetime of
Employee + Family $31.60 $37.99 your participation in this program.
Examples of Services
z Preventive—exams, cleanings, luoride, x-rays,
and sealants
z Basic—illings, simple extractions, and
stainless crowns
z Major—periodontics, repairs, and oral surgery
Implants are not a covered service under the dental
plan.
11
Benefits Guide
Dental
We partner with Delta Dental to ofer 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 Dental coverage provided
Base Option Buy-Up Option
$25 per individual $25 per individual by Delta Dental.
Deductible $75 maximum for $75 maximum for
family family
Annual Dependent Eligibility Note
Maximum $1,000 $1,500
Preventive Care Covered 100% Covered at 100% If your child is 19 years of age or older, and is a full
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
and you pay 20%
and you pay 20%
Major Care The plan pays 50% The plan pays 50% to FTS@deltadentalmo.com: proof of student
and you pay 50%
and you pay 50%
status, document showing the name of the school,
Orthodontia (dependent beneit applies up to age 19) name of the student, class, hours for class and
Coinsurance Not covered Covered at 50% total hours.
Lifetime Not covered $1,000 per eligible
Maximum dependent
Beneit Applies Not applicable Dependent children Remember to visit in-network dentists to receive the
To up to age 19 deepest level of discount on your services.
To ind a participating in-network dentist in your area go to
Dental Contributions www.deltadentalmo.com or call 800.335.8266.
Base Option Buy-Up Option Orthodontia Services Note
Per Pay Period Per Pay Period
Employee Only $11.89 $12.74 The lifetime maximum illustrated is diferent from the
calendar year maximum. For orthodontia services for
Employee + Spouse $24.84 $26.62 children, this limit does not reset each year, this is the most
Employee + Child(ren) $21.47 $27.12 your plan will cover for your services for the lifetime of
Employee + Family $31.60 $37.99 your participation in this program.
Examples of Services
z Preventive—exams, cleanings, luoride, x-rays,
and sealants
z Basic—illings, simple extractions, and
stainless crowns
z Major—periodontics, repairs, and oral surgery
Implants are not a covered service under the dental
plan.
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