Page 18 - 2018 SLU Enrollment
P. 18
Orthodontia Dental
Services Note Access to good oral healthcare can help keep your overall health costs down.
The lifetime maximum illustrated Regular oral health exams can help detect signiicant medical conditions
is different from the calendar before they become serious. For these reasons, we partner with Delta Dental
year maximum. For orthodontia to offer you the ability to choose between two dental plan options. The
services, this limit does not
reset each year, this is the most Flex Plan provides the highest level of beneits and includes adult and child
your plan will cover for your orthodontia. The Basic Plus Plan provides a lower level of beneits with
services for the lifetime of your orthodontia coverage for children only. Both plans offer in- and out-of-
participation in this program. network beneits.
Dental Insurance Your dental beneits and rates will remain the same for the 2018 plan year.
Cards
While not required to receive Dental Plan Highlights
services from a participating
Flex Plan
Basic Plus Plan
dentist, Delta Dental sends ID Schedule of Beneits Delta Dental PPO Delta Dental PPO
Type of Plan
cards to all new enrollees. If Network Considerations In-network Out-of- In-network Out-of-
you need an additional card or network* network*
a replacement card, please call Coinsurance (Plan Pays)
Delta Dental at 314.656.3001 Type A: Preventive Care 100% 100% 100% 50%
or by going online at Type B: Basic 90% 70% 70% 35%
www.deltadentalmo.com. Restorative Services
Type C: Major 60% 40% 40% 20%
Find an In-Network Restorative Services 50% 40% 50% 25%
Type D: Orthodontics
Provider Deductible (applies to) B & C Services B & C Services B & C Services B & C Services
Per Person
$50
$25
$25
$50
Remember to visit in-network Per Family $150 $150 $75 $75
providers to receive the deepest Beneit Maximums
level of discount on your services. Annual Beneit $1,500 $1,500 $1,000 $1,000
To ind a participating in-network Maximum Per Person
$1,000 adult
$1,000 adult
provider in your area go to Lifetime Orthodontia and child (up and child (up $1,000 child $1,000 child
only (up to
Beneit Maximum
only
www.deltadentalmo.com. to age 26) to age 26) age 19) (up to age 19)
* Delta Premier Network or non-participating providers
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in this
guide and what is communicated in your SPD, the terms of your SPD will prevail.
Monthly Premiums Bi-Weekly Premiums
Flex Plan Basic Plus Plan Flex Plan Basic Plus Plan
Employee $37.45 $21.91 $17.28 $10.11
Employee + 1 $73.31 $42.14 $33.84 $19.45
Family $125.52 $75.50 $57.93 $34.85
18 2018 Benefits Enrollment
Services Note Access to good oral healthcare can help keep your overall health costs down.
The lifetime maximum illustrated Regular oral health exams can help detect signiicant medical conditions
is different from the calendar before they become serious. For these reasons, we partner with Delta Dental
year maximum. For orthodontia to offer you the ability to choose between two dental plan options. The
services, this limit does not
reset each year, this is the most Flex Plan provides the highest level of beneits and includes adult and child
your plan will cover for your orthodontia. The Basic Plus Plan provides a lower level of beneits with
services for the lifetime of your orthodontia coverage for children only. Both plans offer in- and out-of-
participation in this program. network beneits.
Dental Insurance Your dental beneits and rates will remain the same for the 2018 plan year.
Cards
While not required to receive Dental Plan Highlights
services from a participating
Flex Plan
Basic Plus Plan
dentist, Delta Dental sends ID Schedule of Beneits Delta Dental PPO Delta Dental PPO
Type of Plan
cards to all new enrollees. If Network Considerations In-network Out-of- In-network Out-of-
you need an additional card or network* network*
a replacement card, please call Coinsurance (Plan Pays)
Delta Dental at 314.656.3001 Type A: Preventive Care 100% 100% 100% 50%
or by going online at Type B: Basic 90% 70% 70% 35%
www.deltadentalmo.com. Restorative Services
Type C: Major 60% 40% 40% 20%
Find an In-Network Restorative Services 50% 40% 50% 25%
Type D: Orthodontics
Provider Deductible (applies to) B & C Services B & C Services B & C Services B & C Services
Per Person
$50
$25
$25
$50
Remember to visit in-network Per Family $150 $150 $75 $75
providers to receive the deepest Beneit Maximums
level of discount on your services. Annual Beneit $1,500 $1,500 $1,000 $1,000
To ind a participating in-network Maximum Per Person
$1,000 adult
$1,000 adult
provider in your area go to Lifetime Orthodontia and child (up and child (up $1,000 child $1,000 child
only (up to
Beneit Maximum
only
www.deltadentalmo.com. to age 26) to age 26) age 19) (up to age 19)
* Delta Premier Network or non-participating providers
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in this
guide and what is communicated in your SPD, the terms of your SPD will prevail.
Monthly Premiums Bi-Weekly Premiums
Flex Plan Basic Plus Plan Flex Plan Basic Plus Plan
Employee $37.45 $21.91 $17.28 $10.11
Employee + 1 $73.31 $42.14 $33.84 $19.45
Family $125.52 $75.50 $57.93 $34.85
18 2018 Benefits Enrollment
