Page 33 - QCS.19 Employee Benefits

2019 Dental Benefits

Dental Care Plus
HMO Dental Plan

You have the option to enroll in our group dental plan. The benefits and your contributions are as
follows:

You are strongly encourage to use an in Benefit In Network
network dentist is order to maximize $25 / $75
your benefits and minimize your out-of- Annual Deductible
pocket cost. To see if your dentist is in Individual/Family $1,000
the network click on Provider Network (waived for Preventive and Covered at 100%
and select the DMHO network. Diagnostic services)
Covered 80% after deductible
Payment to Non Network providers will Annual Maximum
be based on the Network fee schedule, Covered 50% after deductible
and could result in balance billing. Preventive Services
? Oral Exams
Dental Care Plus Customer Service ? Cleanings
800-367-9466 or 513-554-1100 ? X-Rays
? Fluoride Treatment

(through age 18)

? Sealants

Basic Services Include
? Fillings
? Emergency Visits
? Simple Denture Repair
? Basic Oral Surgery
? Simple Extractions
? Endodontic
? Periodontic

Major Services Include:
? Complex Extractions
? Crowns
? Inlays, Onlays
? Bridgework
? Complex / Partial Denture
? Implants

Coverage Election Monthy Per Pay
Employee Only $13.72 $6.33
Employee + Spouse $27.45 $12.67
Employee + Children $28.82 $13.30
Family $45.29 $20.90

For additional plan information, please refer to the detailed plan description provided by the carrier.
In the event of a discrepancy, the carrier Pan Document shall prevail.