Page 13 - Ampact 2022 Benefit Guide

Dental Insurance

It’s important to have regular dental exams and cleanings so
problems are detected before they become painful—and
expensive. Keeping your teeth and gums clean and healthy will
help prevent most tooth decay and periodontal disease and is
an important part of maintaining your medical health.

This dental plan allows you to choose dentists within the Delta
Dental PPO and Premier Networks or dentists outside of the
network (Non-Network Benefits).

Using in-network dental providers
While you have the option of choosing any provider, you will
save money when you use in-network dentists. When using an
out of network dental provider, you will pay more because the
provider has not agreed to charge you a negotiated rate.

How do I find a participating dentist?
Finding a participating dentist is easy. To find a provider or have questions on your dental coverage,
call 1-800-448-3815 or 651-406-5916. You can also visit www.DeltaDentalMN.org.

Provision Delta Dental PPO & Premier Out of Network
Networks
Annual Maximum $2,000 $1,000
Deductible $25 per person $50 per person
$75 per family $150 per family
Preventive & Diagnostic 100% coverage 100% coverage
Teeth cleaning, exams, x-rays,
fluoride treatments and sealers
Basic Restorative Services You pay 0% You pay 20%
Endodontics, Periodontics, Oral You pay 20% You pay 50%
Surgery, Posterior Composite Fillings
Dental rates per pay period

FT PT
Employee $0.00 $0.00
Employee + 1 $9.75 $9.75
Employee + Family $18.96 $18.96

11 13
Effective August 1, 2022-July 31, 2023