Page 18 - 2015 CBRY Enrollment Guide
P. 18
2015 Beneit Guide
Dental Benefits
Dental Beneits We partner with Aetna to offer you and your family members a robust
dental insurance plan. This comprehensive plan allows members to
choose any dentist they prefer to visit. You may experience higher
out-of-pocket expenses when visiting an out-of-network dentist. Aetna
negotiates allowable contract limits with in-network providers. If
your dentist is out-of-network, Aetna will only pay up to the allowable
contract limit and you will be responsible for the balance due.
2015 Dental Beneits
Plan Features In/Out-of-Network
Annual Deductible
Individual $0
Family $0
Calendar Year Maximum (per individual)
$2,000
Preventive Care
Oral exams, cleanings 100% up to allowable contract
(frequency guidelines apply) limits
Basic Dental Care
Fillings, extractions, oral surgery, brush 85% up to allowable contract limits
biopsy, x-rays
Major Dental Care
Inlays, crowns, dentures, bridges 50% of allowable contract limits
Orthodontia (covered at 50%)
Lifetime maximum per individual $2,000
(coverage for children under age 19)
This is a highlight of covered beneits. Please refer to the Summary Plan Description for
detailed information on covered beneits including frequency and age limitations.
2015 Dental Rates
Deduction Per Pay Period
Employee
Employee only $1.38
Employee and Spouse $3.23
Employee and Child/Children $2.77
Employee, Spouse, and Child/Children $4.62
Dental premiums are deducted on a pre-tax basis. Coverage elections can only be changed
during Annual Enrollment unless you experience a qualiied status change.
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Dental Benefits
Dental Beneits We partner with Aetna to offer you and your family members a robust
dental insurance plan. This comprehensive plan allows members to
choose any dentist they prefer to visit. You may experience higher
out-of-pocket expenses when visiting an out-of-network dentist. Aetna
negotiates allowable contract limits with in-network providers. If
your dentist is out-of-network, Aetna will only pay up to the allowable
contract limit and you will be responsible for the balance due.
2015 Dental Beneits
Plan Features In/Out-of-Network
Annual Deductible
Individual $0
Family $0
Calendar Year Maximum (per individual)
$2,000
Preventive Care
Oral exams, cleanings 100% up to allowable contract
(frequency guidelines apply) limits
Basic Dental Care
Fillings, extractions, oral surgery, brush 85% up to allowable contract limits
biopsy, x-rays
Major Dental Care
Inlays, crowns, dentures, bridges 50% of allowable contract limits
Orthodontia (covered at 50%)
Lifetime maximum per individual $2,000
(coverage for children under age 19)
This is a highlight of covered beneits. Please refer to the Summary Plan Description for
detailed information on covered beneits including frequency and age limitations.
2015 Dental Rates
Deduction Per Pay Period
Employee
Employee only $1.38
Employee and Spouse $3.23
Employee and Child/Children $2.77
Employee, Spouse, and Child/Children $4.62
Dental premiums are deducted on a pre-tax basis. Coverage elections can only be changed
during Annual Enrollment unless you experience a qualiied status change.
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