Page 10 - Genesis Care 2022 Benefit Guide

Medical & Spending Voluntary Additional
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DENTAL

Your dental benefits include two plan offerings — the Low Plan and the High Plan. Both plans
are offered through Delta Dental and include regular check-ups, fillings and other important
dental services. While you are able to select a non-participating dentist, staying in-network will
typically save you money. See table below for coverage details.

LOW PLAN HIGH PLAN
DELTA DENTAL
IN-NETWORK IN-NETWORK
PLAN PROVISIONS

Dental Deductible - Individual $50 $50

Dental Deductible - Family $150 $150

Annual Benefit Maximum $1,000 $2,000

Orthodontic Lifetime Maximum $1,000 $1,750

Covered at 100%, Covered at 100%,
Diagnostic and Preventive
deductible waived deductible waived
Basic Services 20% after deductible 20% after deductible

Major Services 50% after deductible 50% after deductible

Orthodontia Services
(covered eligible 50%; deductible waived 50%; deductible waived
dependent children)

Note: "Out-of-network" coverage is offered at the same levels as in-network services but paid based on
negotiated rates.

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