Page 29 - PWH.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 Annual Deductible $50 / $150
your benefits and minimize your out-of- Individual/Family
pocket cost. To see if your dentist is in (waived for Preventive and
the network click on Provider Network Diagnostic services)
and select the DMHO network. Annual Maximum $2,500
Preventive Services Covered at 100%
Oral Exams
•
• Cleanings
Payment to Non Network providers will • X-Rays
be based on the Network fee schedule, • Fluoride Treatment
and could result in balance billing. • (through age 18)
Sealants
Basic Services Include Covered 80% after deductible
• Fillings
Dental Care Plus Customer Service • Emergency Visits
800-367-9466 or 513-554-1100 • Simple Denture Repair
• Basic Oral Surgery
• Simple Extractions
• Endodontic
• Periodontic
Major Services Include: Covered 80% after deductible
• Complex Extractions
• Crowns
• Inlays, Onlays
• Bridgework
• Complex / Partial Denture
• Implants
Orthodontic Services Covered 50%
Limited to eligible dependents $1000 individual lifetime maximum
under 19 years if age

Coverage Election Weekly Monthly
Employee Only $0.00 $0.00
Employee + Spouse $8.51 $36.86
Employee + Children $9.78 $42.36
Family $24.07 $104.32

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.