Page 16 - 2015 DAN Benefits Guide
P. 16
Open
Enrollment
Dental Plan Summary Dental Plan
The dental plan administered by Delta Dental gives you the lexibility
to receive dental care in- or out-of-network, although it usually will
cost you less when you visit a Delta Dental PPO denist. For more
details see the dental plan summary plan descripion posted on
www.DANbeneitsplus.com.
Standard Plan Enhanced Plan
(without Ortho) (with Ortho)
2015 Employee Contribuions Per Pay Period
Employee $4.67 $8.09
Employee + Spouse $9.34 $16.17
Employee + Child(ren) $11.68 $20.22
Family $16.34 $28.30
Carrier Delta Dental Delta Dental
Out-of-
PPO/
Out-of-
PPO/
Network Premier Network Premier Network
Deducible $50/$150 $50/$150
Annual Max $1,000 $2,000
Prevenive 100% 100% 100% 100%
Basic 80% 80% 100% 80%
Major 50% 50% 60% 50%
Ortho (child only to age 19) Not Not 50% to $1,500
Covered Covered
A Note About Dental Coverage
Your annual maximum illustrated here is the most your plan will pay
toward your dental services in a given year. This annual maximum applies
to each person covered on the plan.
The orthodonia limit of $1,500 in the Enhanced Plan is a lifeime
maximum. Unlike your annual maximum, this lifeime orthodonia
maximum is the most your plan will pay for orthodonia services per
member per lifeime. It does not “reset” each year like your annual
maximum.
16
Enrollment
Dental Plan Summary Dental Plan
The dental plan administered by Delta Dental gives you the lexibility
to receive dental care in- or out-of-network, although it usually will
cost you less when you visit a Delta Dental PPO denist. For more
details see the dental plan summary plan descripion posted on
www.DANbeneitsplus.com.
Standard Plan Enhanced Plan
(without Ortho) (with Ortho)
2015 Employee Contribuions Per Pay Period
Employee $4.67 $8.09
Employee + Spouse $9.34 $16.17
Employee + Child(ren) $11.68 $20.22
Family $16.34 $28.30
Carrier Delta Dental Delta Dental
Out-of-
PPO/
Out-of-
PPO/
Network Premier Network Premier Network
Deducible $50/$150 $50/$150
Annual Max $1,000 $2,000
Prevenive 100% 100% 100% 100%
Basic 80% 80% 100% 80%
Major 50% 50% 60% 50%
Ortho (child only to age 19) Not Not 50% to $1,500
Covered Covered
A Note About Dental Coverage
Your annual maximum illustrated here is the most your plan will pay
toward your dental services in a given year. This annual maximum applies
to each person covered on the plan.
The orthodonia limit of $1,500 in the Enhanced Plan is a lifeime
maximum. Unlike your annual maximum, this lifeime orthodonia
maximum is the most your plan will pay for orthodonia services per
member per lifeime. It does not “reset” each year like your annual
maximum.
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