Page 19 - 2018 SLU New Hire Guide
P. 19
Saint Louis University
Dental Orthodontia Services
Access to good oral healthcare can help keep your overall health costs down. Note
Regular oral health exams can help detect signiicant medical conditions The lifetime maximum illustrated
before they become serious. For these reasons, we partner with Delta is different from the calendar year
Dental to offer you the choice between two dental plan options. The Flex maximum. For orthodontia services,
this limit does not reset each year, this
Plan provides the highest level of beneits and includes adult and child is the most your plan will cover for
orthodontia. The Basic Plus Plan provides a lower level of beneits with your services for the lifetime of your
orthodontia coverage for children only. Both plans offer in- and out-of- participation in this program.
network beneits.
Dental Insurance
Dental Plan Highlights Cards
Schedule of Beneits Flex Plan Basic Plus Plan While not required to receive
Type of Plan Delta Dental PPO Delta Dental PPO services from a participating dentist,
Network considerations In-network Out-of- In-network Out-of- Delta Dental sends ID cards to
network* network* all new enrollees. If you need an
Coinsurance (Plan Pays) additional card or a replacement
Type A: preventive 100% 100% 100% 50% card, please call Delta Dental at
care 314.656.3001 or by going online at
Type B: basic 90% 70% 70% 35%
restorative services www.deltadentalmo.com.
Type C: major 60% 40% 40% 20%
restorative services Find an In-Network
Type D: orthodontics 50% 40% 50% 25% Provider
B & C B & C B & C B & C
Deductible (applies to) Services Services Services Services Remember to visit in-network
Per person $50 $50 $25 $25 providers to receive the deepest
Per family $150 $150 $75 $75
Beneit Maximums level of discount on your services.
Annual beneit $1,500 $1,500 $1,000 $1,000 To ind a participating in-network
maximum per person provider in your area go to
Lifetime orthodontia $1,000 adult $1,000 adult $1,000 child $1,000 child www.deltadentalmo.com.
beneit maximum and child (up and child (up only (up to only
to age 26) to age 26) age 19) (up to age
19)
* Delta Premier Network or non-participating providers
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in this
guide and what is communicated in your SPD, the terms of your SPD will prevail.
Monthly Premiums Bi-Weekly Premiums
Flex Plan Basic Plus Plan Flex Plan Basic Plus Plan
Employee $37.45 $21.91 $17.28 $10.11
Employee + 1 $73.31 $42.14 $33.84 $19.45
Family $125.52 $75.50 $57.93 $34.85
19
Dental Orthodontia Services
Access to good oral healthcare can help keep your overall health costs down. Note
Regular oral health exams can help detect signiicant medical conditions The lifetime maximum illustrated
before they become serious. For these reasons, we partner with Delta is different from the calendar year
Dental to offer you the choice between two dental plan options. The Flex maximum. For orthodontia services,
this limit does not reset each year, this
Plan provides the highest level of beneits and includes adult and child is the most your plan will cover for
orthodontia. The Basic Plus Plan provides a lower level of beneits with your services for the lifetime of your
orthodontia coverage for children only. Both plans offer in- and out-of- participation in this program.
network beneits.
Dental Insurance
Dental Plan Highlights Cards
Schedule of Beneits Flex Plan Basic Plus Plan While not required to receive
Type of Plan Delta Dental PPO Delta Dental PPO services from a participating dentist,
Network considerations In-network Out-of- In-network Out-of- Delta Dental sends ID cards to
network* network* all new enrollees. If you need an
Coinsurance (Plan Pays) additional card or a replacement
Type A: preventive 100% 100% 100% 50% card, please call Delta Dental at
care 314.656.3001 or by going online at
Type B: basic 90% 70% 70% 35%
restorative services www.deltadentalmo.com.
Type C: major 60% 40% 40% 20%
restorative services Find an In-Network
Type D: orthodontics 50% 40% 50% 25% Provider
B & C B & C B & C B & C
Deductible (applies to) Services Services Services Services Remember to visit in-network
Per person $50 $50 $25 $25 providers to receive the deepest
Per family $150 $150 $75 $75
Beneit Maximums level of discount on your services.
Annual beneit $1,500 $1,500 $1,000 $1,000 To ind a participating in-network
maximum per person provider in your area go to
Lifetime orthodontia $1,000 adult $1,000 adult $1,000 child $1,000 child www.deltadentalmo.com.
beneit maximum and child (up and child (up only (up to only
to age 26) to age 26) age 19) (up to age
19)
* Delta Premier Network or non-participating providers
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in this
guide and what is communicated in your SPD, the terms of your SPD will prevail.
Monthly Premiums Bi-Weekly Premiums
Flex Plan Basic Plus Plan Flex Plan Basic Plus Plan
Employee $37.45 $21.91 $17.28 $10.11
Employee + 1 $73.31 $42.14 $33.84 $19.45
Family $125.52 $75.50 $57.93 $34.85
19
