Page 17 - 2018 Carlstar Benefit Guide
P. 17
BENEFITS ENROLLMENT • 201817
Dental
The dental coverage offered by The Carlstar Group is designed to assist you and your
covered dependents by paying a portion of eligible expenses incurred for a wide range
of dental services. You may enroll for employee, employee and spouse, employee and
child(ren), or family coverage. The dental plan is through Cigna Dental.
Your Cost
Your cost for Dental coverage is deducted from your pay on a pretax
basis. Refer to page 30 titled “Employee Contributions” for the cost
applicable to dental coverage offered by The Carlstar Group.
Summary of Benefits—Dental
Cigna Beneits Total Cigna DPPO In-Network Out-of-Network
Calendar year maximum $2,000 Class I applies $2,000 Class I applies
(Class I, II, III Expenses)
Calendar year deductible $50 per person $50 per person
$150 per family $150 per family
Class I Expenses 100%, no deductible 100%, no deductible
Preventive and diagnostic care Reimbursement based upon MAC: based on maximum allowable
Oral exams, cleanings, routine x-rays, luoride application, contracted fees charges
sealants, emergency care to relieve pain, brush biopsy
Class II Expenses—Basic Restorative Care 80%, after deductible 80%, after deductible
Space maintainers (limited to non-orthodontic treatment), Reimbursement based upon MAC: based on maximum allowable
non-routine x-rays, illings, oral surgery—simple contracted fees charges
extractions; surgical extraction of impacted teeth; relines,
rebases, and adjustments; repairs—bridges, crowns, and
inlays; repairs—dentures; endodontic procedures—pulp
caps/pulpotomy; periodontal services—non-surgical
services—scaling and root planning
Class III Expenses—Major Restorative Care 50%, after deductible 50%, after deductible
Anesthetics; all periodontal services except scaling and Reimbursement based upon MAC: based on maximum allowable
root planning; endodontic procedures (with the contracted fees charges
Exception of pulp caps/pulpotomy); root canal therapy/
endodontics; crowns/inlays/onlays; dentures; bridges;
stainless steel/resin crowns; surgical implants
Class IV Expenses—Orthodontia 50%, no ortho deductible 50%, no ortho deductible
Coverage for eligible children only (age 18 and under); $2,000 lifetime maximum $2000 lifetime maximum
lifetime maximum; plan deductible does not apply Reimbursement based upon MAC: based on maximum allowable
contracted fees charges
Missing tooth provision Full coverage for replacement of teeth missing prior to the effective
date
Late entrant limit No limit
Pretreatment review Available on a voluntary basis when extensive work in excess of $200
is proposed
Out-of-network reimbursement Based on contracted fee schedule (for location of service rendered);
dentist may balance bill up to usual fees
Student/dependent age 26 26
Dental
The dental coverage offered by The Carlstar Group is designed to assist you and your
covered dependents by paying a portion of eligible expenses incurred for a wide range
of dental services. You may enroll for employee, employee and spouse, employee and
child(ren), or family coverage. The dental plan is through Cigna Dental.
Your Cost
Your cost for Dental coverage is deducted from your pay on a pretax
basis. Refer to page 30 titled “Employee Contributions” for the cost
applicable to dental coverage offered by The Carlstar Group.
Summary of Benefits—Dental
Cigna Beneits Total Cigna DPPO In-Network Out-of-Network
Calendar year maximum $2,000 Class I applies $2,000 Class I applies
(Class I, II, III Expenses)
Calendar year deductible $50 per person $50 per person
$150 per family $150 per family
Class I Expenses 100%, no deductible 100%, no deductible
Preventive and diagnostic care Reimbursement based upon MAC: based on maximum allowable
Oral exams, cleanings, routine x-rays, luoride application, contracted fees charges
sealants, emergency care to relieve pain, brush biopsy
Class II Expenses—Basic Restorative Care 80%, after deductible 80%, after deductible
Space maintainers (limited to non-orthodontic treatment), Reimbursement based upon MAC: based on maximum allowable
non-routine x-rays, illings, oral surgery—simple contracted fees charges
extractions; surgical extraction of impacted teeth; relines,
rebases, and adjustments; repairs—bridges, crowns, and
inlays; repairs—dentures; endodontic procedures—pulp
caps/pulpotomy; periodontal services—non-surgical
services—scaling and root planning
Class III Expenses—Major Restorative Care 50%, after deductible 50%, after deductible
Anesthetics; all periodontal services except scaling and Reimbursement based upon MAC: based on maximum allowable
root planning; endodontic procedures (with the contracted fees charges
Exception of pulp caps/pulpotomy); root canal therapy/
endodontics; crowns/inlays/onlays; dentures; bridges;
stainless steel/resin crowns; surgical implants
Class IV Expenses—Orthodontia 50%, no ortho deductible 50%, no ortho deductible
Coverage for eligible children only (age 18 and under); $2,000 lifetime maximum $2000 lifetime maximum
lifetime maximum; plan deductible does not apply Reimbursement based upon MAC: based on maximum allowable
contracted fees charges
Missing tooth provision Full coverage for replacement of teeth missing prior to the effective
date
Late entrant limit No limit
Pretreatment review Available on a voluntary basis when extensive work in excess of $200
is proposed
Out-of-network reimbursement Based on contracted fee schedule (for location of service rendered);
dentist may balance bill up to usual fees
Student/dependent age 26 26
