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Dental
Dental PPO/Premier
Our dental plan makes Calendar Year Deductible In-Network Out-of-Network
dental care more affordable Individual $50 $50
for associates and their Family $150 $150
Coinsurance
families. We partner with Preventive 100% 100%
Delta Dental of IL to offer Basic 80% 80%
Major
50%
50%
you comprehensive dental Calendar Year Maximum
coverage options. Keep in $1,200 $1,200
mind, the information in the Orthodontia 50% 50%
Coinsurance
chart provided is a summary Lifetime Maximum $1,000 $1,000
only. Please refer to your Beneit Applies to Children under age 19 Children under age 19
Visits and Exams
Certiicate of Coverage Visit for Oral Examination 2 per beneit year 2 per beneit year
(COC) for complete details Prophylaxis, Including Scaling 2 per beneit year 2 per beneit year
on OTL. and Polishing Once per beneit year Once per beneit year
Fluoride
Children under age 19 Children under age 19
Delta Dental of Illinois Sealants Under age 16 Under age 16
X-Rays
offers two networks: a Bitewing X-rays 2 per beneit year 2 per beneit year
Premier network and a Full Mouth X-rays Once every three years Once every three years
PPO network. While the Endodontics Covered at 80% Covered at 80%
Pulpotomy
Premier network offers Apicoectomy Covered at 80% Covered at 80%
deep discounts, you will Minor Restorations
ind the greatest discounts Amalgam (silver) Fillings Covered at 80% Covered at 80%
Composite Fillings (anterior
Covered at 80%
Covered at 80%
with providers who are teeth only)
under the PPO network. Stainless Steel Crowns Covered at 50% Covered at 50%
Covered at 80%
Covered at 80%
Uncomplicated Extractions
Most providers in the PPO Surgical Removal of Erupted Covered at 80% Covered at 80%
network are also in the Tooth Covered at 50% Covered at 50%
Inlays
Premier network because Onlays Covered at 50% Covered at 50%
the Premier network is Crowns Covered at 50% Covered at 50%
a larger network. Visit Full and Partial Dentures Covered at 50% Covered at 50%
Covered at 50%
Denture Repairs
Covered at 50%
www.deltadentalil.com.
Benefit Compensation
Bi-weekly Rates < $92,500 ≥ $92,500
Associate Only $9.42 $10.76
Associate + Spouse $21.53 $24.22
Associate + Child(ren) $26.76 $30.10
Family $43.74 $49.21
Benefits Enrollment
Dental
Dental PPO/Premier
Our dental plan makes Calendar Year Deductible In-Network Out-of-Network
dental care more affordable Individual $50 $50
for associates and their Family $150 $150
Coinsurance
families. We partner with Preventive 100% 100%
Delta Dental of IL to offer Basic 80% 80%
Major
50%
50%
you comprehensive dental Calendar Year Maximum
coverage options. Keep in $1,200 $1,200
mind, the information in the Orthodontia 50% 50%
Coinsurance
chart provided is a summary Lifetime Maximum $1,000 $1,000
only. Please refer to your Beneit Applies to Children under age 19 Children under age 19
Visits and Exams
Certiicate of Coverage Visit for Oral Examination 2 per beneit year 2 per beneit year
(COC) for complete details Prophylaxis, Including Scaling 2 per beneit year 2 per beneit year
on OTL. and Polishing Once per beneit year Once per beneit year
Fluoride
Children under age 19 Children under age 19
Delta Dental of Illinois Sealants Under age 16 Under age 16
X-Rays
offers two networks: a Bitewing X-rays 2 per beneit year 2 per beneit year
Premier network and a Full Mouth X-rays Once every three years Once every three years
PPO network. While the Endodontics Covered at 80% Covered at 80%
Pulpotomy
Premier network offers Apicoectomy Covered at 80% Covered at 80%
deep discounts, you will Minor Restorations
ind the greatest discounts Amalgam (silver) Fillings Covered at 80% Covered at 80%
Composite Fillings (anterior
Covered at 80%
Covered at 80%
with providers who are teeth only)
under the PPO network. Stainless Steel Crowns Covered at 50% Covered at 50%
Covered at 80%
Covered at 80%
Uncomplicated Extractions
Most providers in the PPO Surgical Removal of Erupted Covered at 80% Covered at 80%
network are also in the Tooth Covered at 50% Covered at 50%
Inlays
Premier network because Onlays Covered at 50% Covered at 50%
the Premier network is Crowns Covered at 50% Covered at 50%
a larger network. Visit Full and Partial Dentures Covered at 50% Covered at 50%
Covered at 50%
Denture Repairs
Covered at 50%
www.deltadentalil.com.
Benefit Compensation
Bi-weekly Rates < $92,500 ≥ $92,500
Associate Only $9.42 $10.76
Associate + Spouse $21.53 $24.22
Associate + Child(ren) $26.76 $30.10
Family $43.74 $49.21
Benefits Enrollment
