Page 24 - Skechers 2022 Benefits Guide

DENTAL & VISION
DELTA DENTAL PLAN OVERVIEW
Keeping your teeth and gums healthy is just as important as taking care of the rest of your body. As
a benefits-eligible employee, you may choose between two dental plans, Delta Dental HMO** and Delta Dental PPO.
DELTA HMO PLAN**
You are required to select a Primary Care Dentist who will be in charge of all of your dental services under the Dental HMO Plan. To find a Primary Care Dentist near you, please visit Delta Dental’s website (deltadentalins.com) or call. While on the website, please select 'Delta Care USA' under Select Network. This plan is not available in HI, VT, ND and Puerto Rico.
HMO Call: 800-422-4234
Services
Calendar Year Deductible
Maximum Calendar Year Benefit
Diagnostic & Preventive—oral exam, basic cleanings, diagnostic X-rays
Basic Services—restorative (fillings), endodontics, periodontics, simple extractions
Major Services—inlays, onlays
Major Services—crowns, dentures
Orthodontic Services—children (up to age 19)
Orthodontic Services—adults
DELTA PPO PLAN*
You may access care with any Delta PPO provider or any licensed provider of your choice under the PPO plan. To find a participating PPO provider near you, please visit Delta Dental’s website (deltadentalins.com) or call. While on the website, please select 'Delta Dental PPO' under Select Network.
DENTAL PLAN CONTRIBUTIONS***
HMO Providers
None
Unlimited
Up to $45 Copay1
Up to $310 Copay1
Up to $310 Copay1
Up to $310 Copay1
$1,700 Copay1
$1,900 Copay1
PPO Providers
Non-PPO Providers
For PPO Call: 800-765-6003
DELTA DENTAL HMO**
DELTA DENTAL PPO*
Your Cost Share Shown Below
Contribution
Employee
Employee + Spouse/ Domestic Partner
Employee + Child(ren)
Employee + Family
HMO
$4.00
$8.00
$12.00
$12.50
PPO
$8.00
$16.75
$27.00
$27.50
$50 Individual/$150 Family
$2,000
No Charge2
No Charge2
***Your cost per paycheck (pre-tax). When you become eligible for the Plan, your benefits become effective on the 31st day of employment and you will be responsible for all per paycheck costs in the pay period in which your 31st day falls. If you become ineligible for the plan, your benefits terminate on the last day of the month in which you become ineligible, and you will be responsible for all per paycheck costs for the month. Benefits costs are NOT prorated.
24 SKECHERS
10% 20%
40% 50%
40% 50%
50% up to a lifetime maximum of $1,000
1Additional copays may apply. Refer to Delta Dental HMO copay schedule in the Reference Center. 2Deductible Waived *Available in all US states and Puerto Rico, excluding Hawaii. **Delta Dental HMO not available in HI, VT, ND and Puerto Rico