Page 20 - 2017 US Benefits Guide - for all Capgemni employees in the FS SBU
P. 20
Dental Plan Comparison Chart What is a maximum
plan allowance?
DMO The maximum plan
Covered Services Enhanced Dental (In-Network Only) Basic Dental PPO allowance is the amount
Deductible (Individual/Family) $25/$75 $0 $50/$150 that a Delta Dental Premier
Dentist agrees contractually
Maximum Benefit to accept as full payment
Dental Services $1,500 per plan year $1,000 per plan year for covered procedures.
Orthodontia Services $2,000 per lifetime No limit N/A The maximum plan
allowance is calculated as
Non-Surgical Temporomandibular No coverage N/A a percentile of billed fees.
Joint Dysfunction (TMJ)
Delta Dental PPO and
Diagnostic & Preventive
Services (deductible waived) Premier Dentists are
Co-insurance 1 100% Costs based on patient 100% required to accept the
charge schedule 2 Delta Dental of Illinois
Oral Exams 2 visits per plan year 2 visits per plan year approved fee as full
reimbursement for their
Cleaning 2 visits per plan year All oral exams and X-rays 2 visits per plan year services. If you visit an
X-rays Bite wing – are covered at 100% Bite wing – out-of-network provider
2 per plan year 2 per plan year who charges fees higher
Complete series – Complete series – than the maximum plan
1 during any 36 months 1 during any 36 months allowance, you will be
Basic Services (co-insurance) 1 responsible for paying
Basic Restorations, Endodontics, 80% after deductible Costs based on patient 80% the diference.
Periodontics charge schedule 2
Major Services (co-insurance) 1
Crowns, Inlays/Onlays, Full or Partial 50% after deductible Costs based on patient No coverage
Dentures charge schedule 2
Orthodontic Services 50% after deductible Costs based on patient No coverage
(co-insurance) 1 charge schedule 2
Non-Surgical Temporomandibular No coverage Costs based on patient No coverage
Joint Dysfunction (TMJ) charge schedule 2
(co-insurance) 1
1 Co-insurance relects the portion of costs that the Company pays.
2 The patient charge schedule is available on the Capgemini FS benergy site at www.capgeminiFS.benergy.com under Dental.
CAPGEMINI 2017 BENEFITS GUIDE 17
plan allowance?
DMO The maximum plan
Covered Services Enhanced Dental (In-Network Only) Basic Dental PPO allowance is the amount
Deductible (Individual/Family) $25/$75 $0 $50/$150 that a Delta Dental Premier
Dentist agrees contractually
Maximum Benefit to accept as full payment
Dental Services $1,500 per plan year $1,000 per plan year for covered procedures.
Orthodontia Services $2,000 per lifetime No limit N/A The maximum plan
allowance is calculated as
Non-Surgical Temporomandibular No coverage N/A a percentile of billed fees.
Joint Dysfunction (TMJ)
Delta Dental PPO and
Diagnostic & Preventive
Services (deductible waived) Premier Dentists are
Co-insurance 1 100% Costs based on patient 100% required to accept the
charge schedule 2 Delta Dental of Illinois
Oral Exams 2 visits per plan year 2 visits per plan year approved fee as full
reimbursement for their
Cleaning 2 visits per plan year All oral exams and X-rays 2 visits per plan year services. If you visit an
X-rays Bite wing – are covered at 100% Bite wing – out-of-network provider
2 per plan year 2 per plan year who charges fees higher
Complete series – Complete series – than the maximum plan
1 during any 36 months 1 during any 36 months allowance, you will be
Basic Services (co-insurance) 1 responsible for paying
Basic Restorations, Endodontics, 80% after deductible Costs based on patient 80% the diference.
Periodontics charge schedule 2
Major Services (co-insurance) 1
Crowns, Inlays/Onlays, Full or Partial 50% after deductible Costs based on patient No coverage
Dentures charge schedule 2
Orthodontic Services 50% after deductible Costs based on patient No coverage
(co-insurance) 1 charge schedule 2
Non-Surgical Temporomandibular No coverage Costs based on patient No coverage
Joint Dysfunction (TMJ) charge schedule 2
(co-insurance) 1
1 Co-insurance relects the portion of costs that the Company pays.
2 The patient charge schedule is available on the Capgemini FS benergy site at www.capgeminiFS.benergy.com under Dental.
CAPGEMINI 2017 BENEFITS GUIDE 17
