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P. 10
2016 Benefits Enrollment
Dental
Find a Provider Delta Dental of Illinois
1. Go to Delta Dental’s plan gives you access to Delta Dental’s PPO and Premier
www.deltadentalil.com networks, which are the largest dental provider networks in the nation.
and click the provider You have the freedom to choose any dentist. However, you will receive the
search link. Select “Find deepest savings if you choose a Delta Dental PPO dentist. All Delta Dental
a Network Dentist” from network dentists ile claims for you and your family when you provide your
the drop down menu. identiication card—no paperwork for you!
2. Call 800.323.1743, say Delta Dental of Illinois
“Dentist Directory” and PPO Network Premier Network Out-of-Network*
follow the automated Deductible (Plan Year)
$50
$50
$50
instructions. Individual $100 $100 $100
Family
3. Call your dentist’s ofice Coinsurance—Percent You Pay
and ask if they are a Preventive services: 100% covered 100% covered 100% covered
exams, x-rays,
participating Delta Dental prophylaxis
80% after
80% after
PPO or Premier network Basic services: illings, deductible 80% after deductible
deductible
oral surgery, root canals
dentist. Major services: bridges, 50% after 50% after 50% after
crowns, dentures deductible deductible deductible
Plan Year Maximum
$1,000 $1,000 $1,000
Orthodontist Services
Dependent children 50% no deductible 50% no deductible 50% no deductible
Adults
Orthodontist lifetime $1,500 $1,500 $1,500
maximum
* Please note, if you see an out-of-network provider, Delta Dental will reimburse according to the
maximum allowable charge.
Dental Contribution Rates
This chart illustrates your weekly, bi-weekly, and/or monthly pre-tax
contributions for the Optimas dental plan.
Dental Plan
All Employees Weekly Bi-Weekly Monthly
Employee only $4.04 $8.07 $17.49
Employee + spouse $9.09 $18.19 $39.41
Employee + child(ren) $7.77 $15.54 $33.66
Family $13.36 $26.73 $57.91
10
Dental
Find a Provider Delta Dental of Illinois
1. Go to Delta Dental’s plan gives you access to Delta Dental’s PPO and Premier
www.deltadentalil.com networks, which are the largest dental provider networks in the nation.
and click the provider You have the freedom to choose any dentist. However, you will receive the
search link. Select “Find deepest savings if you choose a Delta Dental PPO dentist. All Delta Dental
a Network Dentist” from network dentists ile claims for you and your family when you provide your
the drop down menu. identiication card—no paperwork for you!
2. Call 800.323.1743, say Delta Dental of Illinois
“Dentist Directory” and PPO Network Premier Network Out-of-Network*
follow the automated Deductible (Plan Year)
$50
$50
$50
instructions. Individual $100 $100 $100
Family
3. Call your dentist’s ofice Coinsurance—Percent You Pay
and ask if they are a Preventive services: 100% covered 100% covered 100% covered
exams, x-rays,
participating Delta Dental prophylaxis
80% after
80% after
PPO or Premier network Basic services: illings, deductible 80% after deductible
deductible
oral surgery, root canals
dentist. Major services: bridges, 50% after 50% after 50% after
crowns, dentures deductible deductible deductible
Plan Year Maximum
$1,000 $1,000 $1,000
Orthodontist Services
Dependent children 50% no deductible 50% no deductible 50% no deductible
Adults
Orthodontist lifetime $1,500 $1,500 $1,500
maximum
* Please note, if you see an out-of-network provider, Delta Dental will reimburse according to the
maximum allowable charge.
Dental Contribution Rates
This chart illustrates your weekly, bi-weekly, and/or monthly pre-tax
contributions for the Optimas dental plan.
Dental Plan
All Employees Weekly Bi-Weekly Monthly
Employee only $4.04 $8.07 $17.49
Employee + spouse $9.09 $18.19 $39.41
Employee + child(ren) $7.77 $15.54 $33.66
Family $13.36 $26.73 $57.91
10
