Page 4 - 2015 Benefits Guide
P. 4
OPEN ENROLLMENT 2015
Dental
Greenville Regional Hospital will be renewing our dental plan with BlueCross BlueShield of Illinois. Effective
January 1, 2015 we will be offering two dental plan options: one plan with orthodontia coverage and the second
without orthodontia coverage. You are allowed to enroll dependents in the dental plan up to age 19 or age 23 if he
or she is a full-time student.
Blue Cross of Illinois with Orthodontia Beneits—Effective January 1, 2015
PPO Non-PPO
Charges subject to reasonable and customary allowance
Calendar Year Deductible
Individual $25 $50
Family $75 $150
Calendar Year Maximum $1,500 $1,500
Coinsurance
Preventive and Diagnostic 100% no deductible 80% no deductible
Basic Restorative 90% after deductible 80% after deductible
Major Restorative 60% after deductible 50% after deductible
Orthodontic (dependent children
to age 19 only) 50% to $1,500 LT 50% to $1,000 LT
Covered Under Preventive
Dental Exams, Cleanings, Fluoride Treatment, X-rays, Space Maintainers, and Sealants
Covered Under Basic
Routine Fillings (amalgams and resins), Simple Extractions, Stainless Steel Crowns, Endodontics (root
canal therapy), Periodontic Services, General Anesthesia, and Simple Extractions
Covered Under Major
Major Restorative Services—Crowns, Inlays, Onlays, Prosthodontic Services, and Oral Surgery
NEW—Blue Cross of Illinois without Orthodontia Beneits—Effective January 1, 2015
PPO Non-PPO
Charges subject to reasonable and customary allowance
Calendar Year Deductible
Individual $25 $50
Family $75 $150
Calendar Year Maximum $1,500 $1,500
Coinsurance
Preventive and Diagnostic 100% no deductible 80% no deductible
Basic Restorative 90% after deductible 80% after deductible
Major Restorative 60% after deductible 50% after deductible
Covered Under Preventive
Dental Exams, Cleanings, Fluoride Treatment, X-rays, Space Maintainers, and Sealants
Covered Under Basic
Routine Fillings (amalgams and resins), Simple Extractions, Stainless Steel Crowns, Endodontics (root
canal therapy), Periodontic Services, General Anesthesia, and Simple Extractions
Covered Under Major
Major Restorative Services—Crowns, Inlays, Onlays, Prosthodontic Services, and Oral Surgery
4
Dental
Greenville Regional Hospital will be renewing our dental plan with BlueCross BlueShield of Illinois. Effective
January 1, 2015 we will be offering two dental plan options: one plan with orthodontia coverage and the second
without orthodontia coverage. You are allowed to enroll dependents in the dental plan up to age 19 or age 23 if he
or she is a full-time student.
Blue Cross of Illinois with Orthodontia Beneits—Effective January 1, 2015
PPO Non-PPO
Charges subject to reasonable and customary allowance
Calendar Year Deductible
Individual $25 $50
Family $75 $150
Calendar Year Maximum $1,500 $1,500
Coinsurance
Preventive and Diagnostic 100% no deductible 80% no deductible
Basic Restorative 90% after deductible 80% after deductible
Major Restorative 60% after deductible 50% after deductible
Orthodontic (dependent children
to age 19 only) 50% to $1,500 LT 50% to $1,000 LT
Covered Under Preventive
Dental Exams, Cleanings, Fluoride Treatment, X-rays, Space Maintainers, and Sealants
Covered Under Basic
Routine Fillings (amalgams and resins), Simple Extractions, Stainless Steel Crowns, Endodontics (root
canal therapy), Periodontic Services, General Anesthesia, and Simple Extractions
Covered Under Major
Major Restorative Services—Crowns, Inlays, Onlays, Prosthodontic Services, and Oral Surgery
NEW—Blue Cross of Illinois without Orthodontia Beneits—Effective January 1, 2015
PPO Non-PPO
Charges subject to reasonable and customary allowance
Calendar Year Deductible
Individual $25 $50
Family $75 $150
Calendar Year Maximum $1,500 $1,500
Coinsurance
Preventive and Diagnostic 100% no deductible 80% no deductible
Basic Restorative 90% after deductible 80% after deductible
Major Restorative 60% after deductible 50% after deductible
Covered Under Preventive
Dental Exams, Cleanings, Fluoride Treatment, X-rays, Space Maintainers, and Sealants
Covered Under Basic
Routine Fillings (amalgams and resins), Simple Extractions, Stainless Steel Crowns, Endodontics (root
canal therapy), Periodontic Services, General Anesthesia, and Simple Extractions
Covered Under Major
Major Restorative Services—Crowns, Inlays, Onlays, Prosthodontic Services, and Oral Surgery
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