Page 10 - 2022 Fives Landis Corp Benefit Guide

DENTAL COVERAGE

Regular dental exams can help you and your dentist
detect problems in the early stages when treatment is
simpler and costs are lower. Keeping your teeth and gums
clean and healthy will help prevent most tooth decay and
periodontal disease, and is an important part of maintaining To find a provider participating in your dental plan network,
your medical health. visit: www.deltadentalmi.com or call 800-524-0149

Download the APP for easy access to claims, virtual ID Card,
Your dental plan will be administered by Delta Dental of plan benefits and more.
Michigan.

The Dental plan does not require in-network providers be
used, however, Delta Dental network providers will charge
lower fees thereby making your dental dollars go further
and lowering your out of pocket costs.

Delta Dental PPO and
Delta Dental Premier

Delta Dental of Michigan
Plan Provision
$750 Plan $1,500 Plan

Annual deductible (Individual/Family) $50/ $100 $50/$100
Annual maximum (per person) $750 $1,500

Diagnostic and preventive care: Includes cleanings, fluoride treatments, seal- 100%, no deductible 100%, no deductible
ants and x-rays per plan limits.
Basic Services: Includes fillings, periodontics, scaling and root planning, and 80% after deductible 80% after deductible
oral surgery
Major Services: Includes crowns, bridges and full and partial dentures 50% after deductible 50% after deductible

50% after deducible, $750 50% after deductible $1,500
Orthodontia (up to age 19)
lifetime maximum lifetime maximum
Coverage Level 2022 Dental rates (bi-weekly)

Employee Only $0 $5.98

Employee + Spouse $0 $11.95

Employee + Child(ren) $0 $10.76
Family $0 $17.93

7