Page 14 - 2022 US Benefits Guide FINAL

DENTAL PLAN

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 is an important part of maintaining your overall health. We offer
dental through Delta Dental of IL. Members with conditions such as gum disease, diabetes, high
risk cardiac conditions and pregnancy are eligible for the Enhanced Benefit Program.

Click here to watch a short video with more information on our dental plan.

Plan Provisions Delta Dental PPO Network Delta Dental Premier Network Out-of-Network

Annual Deductible $100 / $300
(Individual/Family)
Calendar Year Maximum $1,500 Per Person
Orthodontia Lifetime $2,000 Per Dependent $1,000 Per Dependent $1,000 Per Dependent
Maximum
Diagnostic and Preventive
Services (e.g., X-rays, 100% 100% 100%
cleanings, exams)
Basic and Restorative 80% 80% 80%
Services (e.g., fillings)
Major Services (e.g.,
dentures, 50% 50% 50%
crowns, bridges)

Orthodontia 50% for children under age 19 50% for children under age 19 50% for children under age 19

Using in-network dental providers

While you have the option of choosing any provider, you will save money when you use in-

network dentists. Delta offers two dental networks.

Delta Dental PPO dentists accept payment based on the lesser of the submitted fee (their
usual fee) or Delta Dental’s allowed PPO fee. PPO network dentists cannot charge you for
costs exceeding the PPO fee.

Delta Dental Premier dentists accept payment based on the lesser of the submitted fee
(their usual fee) or Delta Dental’s maximum plan allowance. Premier dentists may not
charge you for costs exceeding the maximum plan allowance.
If you use an out-of-network dental provider, you will pay more because the provider has
not agreed to charge you a negotiated rate.

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