Page 11 - Citizens Bank Benefit Guide 2020_Revised 12-11-2020

Dental Option:

Delta Dental

Per Pay Period
Dependent-Information
COVERED ON Covered ON Covered ON Covered ON NOT COVERED ON
Per Pay Period MEDICAL as MEDICAL as MEDICAL as MEDICAL as MEDICAL Our employees the opportunity to
EO ES EC EF Without Coverage cover their spouse and dependent
children. Eligible children can join
Employee Only $ 0.00 $ 0.00 $ 0.00 $0.00 $19.89
or remain on parent’s dental plan
until age 26. When an eligible child
Employee + Spouse $19.88 $ 0.00 $ 0.00 $0.00 $39.77
turns 26, they will lose dental cov-
Employee + Child(ren) $36.47 $16.59 $ 0.00 $0.00 $56.36 erage on the last day of their birth
month.
Employee + Family $56.35 $36.47 $19.88 $0.00 $76.24

(In-Network) Plan Coverage Dentists in the PPO
Type of Service
and Delta Dental Plus Premier Networks

Class I: Diagnostic & Preventive Services Covered at 100%; No Deductible

Class II: Basic Services Covered at 80% after Calendar Year Deductible

Class III: Major Services Covered at 50% after Calendar Year Deductible

Covered at 50% after Calendar Year Deductible for dependent
Class IV: Orthodontic Services
children up to age 26
Calendar Year Deductible $50 Individual / $150 Family
$1,500 per person—Benefits are paid by the Plan for covered oral
evaluations and routine cleanings will not reduce your Maximum
Annual Maximum
benefit per person for combined Class I, II, and III covered dental
services. $1,500 lifetime maximum applies to Orthodontics Class IV.
Delta PPO Network providers have the greatest savings. Premier
In Network Providers Network are reimbursed at PPO maximums and still have savings
greater than out of network providers.

Out of Network Providers NO Network savings and much higher out of pocket costs

Type of Service Benefit Description

Oral Exams, Cleanings, X-rays, Sealants, Fluoride Treatment for
Preventive Services
children under age18)
Amalgam & Composite Fillings, Simple Extractions, Oral Surgery,
Basic Services
Endodontics, Periodontics
Major Services Crowns, Dentures, and Implants

Orthodontic Services Covered for dependent children under age 26 only

Annual Maximum Applies January 1 to December 31

NOTE: This is only a brief overview. Please see Benefit Summary for more details.
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Website: www.deltadentalOK.org or Customer Service: 800-522-0188