Page 11 - 2022 Citizens Bank Benefit Guide

Dental Option:

Delta Dental

Per Pay Period
COVERED ON Covered ON Covered ON Covered ON NOT COVERED ON Dependent-Information
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
Employee Only $ 0.00 $ 0.00 $ 0.00 $0.00 $19.89 children. Eligible children can join or
remain on parent’s dental plan until
Employee + Spouse $19.88 $ 0.00 $ 0.00 $0.00 $39.77 age 26. When an eligible child turns
26, they will lose dental coverage
Employee + Child(ren) $36.47 $16.59 $ 0.00 $0.00 $56.36 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