Page 9 - 2022 Benefit Guide FNA Combustion

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
your medical health.
participating in your dental
Your dental plan will be administered by Delta Dental of Michigan. plan network, visit
www.deltadentalmi.com
The Dental plan does not require use of in-network providers; however, Delta Dental network
or call 800-524-0149
providers will charge lower fees thereby making your dental dollars go farther and lowering your
out of pocket costs.

Delta Dental of Michigan
Plan Provision
$750 Plan $1500 Plan
Annual deductible (Individual/Family) $50/$100 $50/$100

Annual maximum (per person) $750 $1,500
Diagnostic and preventive care: Includes
cleanings, fluoride treatments, sealants and x- 100%, no deductible 100%, no deductible
rays per plan limits

Basic Services: Includes fillings, periodontics, 80% after deductible 80% after deductible
scaling and root planning, and oral surgery

Major Services: Includes crowns, bridges and full 50% after deductible 50% after deductible
and partial dentures

50% after deducible, $750 lifetime 50% after deductible $1,500 lifetime
Orthodontia (up to age 19)
maximum maximum
Coverage Level 2022 Dental Rates Monthly

Employee Only $9.38 $14.97
Employee +Spouse $18.75 $29.91

Employee + Child(ren) $16.88 $26.93
Family $28.13 $44.88

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