Page 19 - 2017 US Benefits Guide - for all Capgemni employees in the FS SBU
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Basic Dental PPO A truly healthy smile.
In the Basic Dental PPO Plan, you can visit any dental provider you wish; however, visiting Improving oral health has been shown to
in-network providers can reduce your out-of-pocket expenses because these providers agree lower medical costs for individuals with
to perform services for Delta Dental’s maximum allowable charges and will not bill you for any diabetes and cardiovascular disease.
charges over those amounts. Basic Dental covers diagnostic and preventive services, such
as cleanings and X-rays, and basic services, such as basic restorations, endodontics and Open up and say, “How much?”
periodontics. It does not cover major services or orthodontia. For more information about the If you are enrolled in the Basic or
Basic Dental PPO Plan, visit the Capgemini FS benergy site at www.capgeminiFS.benergy.com Enhanced Dental Plan, ask your dentist
under Dental. to submit a predetermination to Delta
Choose Your Dentist Dental for dental procedures in excess of
$250. This way, you’ll know your costs
Locate a participating dental provider in your area in the Find a Dentist section of Delta Dental’s before services are rendered.
website at www.deltadental.com .
Dental Plan Rates
Semi-Monthly Employee Contribution
Coverage Level Enhanced Plan Basic Plan DMO Plan
You Only $5.45 $3.27 $2.89
You + Spouse/Domestic Partner $10.90 $6.54 $5.21
You + Child(ren) $12.54 $7.52 $6.60
You + Family $18.53 $11.12 $9.77
Coverage levels can include any eligible dependents defined under the Benefits Eligibility section.
The rates shown do not apply to COBRA participants.
CAPGEMINI 2017 BENEFITS GUIDE 16
In the Basic Dental PPO Plan, you can visit any dental provider you wish; however, visiting Improving oral health has been shown to
in-network providers can reduce your out-of-pocket expenses because these providers agree lower medical costs for individuals with
to perform services for Delta Dental’s maximum allowable charges and will not bill you for any diabetes and cardiovascular disease.
charges over those amounts. Basic Dental covers diagnostic and preventive services, such
as cleanings and X-rays, and basic services, such as basic restorations, endodontics and Open up and say, “How much?”
periodontics. It does not cover major services or orthodontia. For more information about the If you are enrolled in the Basic or
Basic Dental PPO Plan, visit the Capgemini FS benergy site at www.capgeminiFS.benergy.com Enhanced Dental Plan, ask your dentist
under Dental. to submit a predetermination to Delta
Choose Your Dentist Dental for dental procedures in excess of
$250. This way, you’ll know your costs
Locate a participating dental provider in your area in the Find a Dentist section of Delta Dental’s before services are rendered.
website at www.deltadental.com .
Dental Plan Rates
Semi-Monthly Employee Contribution
Coverage Level Enhanced Plan Basic Plan DMO Plan
You Only $5.45 $3.27 $2.89
You + Spouse/Domestic Partner $10.90 $6.54 $5.21
You + Child(ren) $12.54 $7.52 $6.60
You + Family $18.53 $11.12 $9.77
Coverage levels can include any eligible dependents defined under the Benefits Eligibility section.
The rates shown do not apply to COBRA participants.
CAPGEMINI 2017 BENEFITS GUIDE 16
