Page 10 - Tessenderlo Kerley, Inc 2022 Benefit Guide

DELTA DENTAL PLAN - NEW PROVIDER FOR 2022

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 a dental plan
through Delta Dental of AZ.

Delta Dental Plan
Using in-network dental providers
Plan Provisions In-Network Out-of-Network
While you have the option of choosing any provider, you will
Annual Deductible save money when you use in-network dentists. When using an
(Individual/Family) None out-of-network dental provider, you will pay more because the
Calendar Year Maximum $1,500 per individual provider has not agreed to charge you a negotiated rate.
Orthodontia Lifetime Maximum $2,000 per individual

Diagnostic and Preventive Services Monthly Premiums
i
(e.g., X-rays, clean ngs, exams) Covered at 100% Covered at 100%
Coverage Level Delta Dental Plan
Basic and Restorative Services
(e.g., fillings) 80%* 80%* Employee Only $10
Major Services Employee + Spouse $22
(e.g., dentures, crowns, bridges) 50%* 50%*
Orthodontia 50%* for adults & children Employee + Child(ren) $25
*After deductible Employee + Family $32

WELCOME BENEFIT BASICS MEDICAL DENTAL VISION FSA ADDITIONAL BENEFITS 401(k) CONTACTS LEGAL RIGHTS 10