Page 14 - 2016 Open Enrollment Non-Union
P. 14
Beneits Enrollment
Preventive Dental Care
When it comes to the health of your Dental Benefits
teeth and gums, preventive dental care In-Network Out-of-Network
is smart. Brushing and lossing help to Annual Deductible $50 Single/$150 $50 Single/$150
remove plaque from the surfaces and Waived for orthodontia and Family Family
in between teeth, keeping your teeth preventive treatment
looking and feeling clean. Routine dental Maximum annual beneit $1,750 per person $1,500 per person
exams and regular cleanings may help Preventive Services Plan pays 100% Plan pays 100%
prevent the incidence of higher-cost Includes exams and cleanings, of reasonable and
luoride treatments, x-rays for
customary (R&C)
treatments such as periodontal surgery, diagnosis, sealants
root canals, extractions, and illings. Basic Services Plan pays 80% Plan pays 80%
Includes illings and extractions, of R&C after
periodontics, repairs to crowns deductible
or dentures, endodontics, oral
surgery *
Major Care Services Plan pays 50% Plan pays
Includes crowns, inlays, dentures, 50% of R&C after
dental implants deductible
Orthodontic services Plan pays 50% Plan pays
coverage for dependents to age 19 50% of R&C
Maximum lifetime orthodontia $1,750 per person $1,500 per person
beneit
* Please note: oral surgery beneits apply to your calendar year maximum
Dental Rates as of January 1, 2016
Dental Plan Monthly Employee Contribution
Employee (Ee) $10.55
Ee + spouse $22.15
Ee + child(ren) $18.98
Family $33.74
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Preventive Dental Care
When it comes to the health of your Dental Benefits
teeth and gums, preventive dental care In-Network Out-of-Network
is smart. Brushing and lossing help to Annual Deductible $50 Single/$150 $50 Single/$150
remove plaque from the surfaces and Waived for orthodontia and Family Family
in between teeth, keeping your teeth preventive treatment
looking and feeling clean. Routine dental Maximum annual beneit $1,750 per person $1,500 per person
exams and regular cleanings may help Preventive Services Plan pays 100% Plan pays 100%
prevent the incidence of higher-cost Includes exams and cleanings, of reasonable and
luoride treatments, x-rays for
customary (R&C)
treatments such as periodontal surgery, diagnosis, sealants
root canals, extractions, and illings. Basic Services Plan pays 80% Plan pays 80%
Includes illings and extractions, of R&C after
periodontics, repairs to crowns deductible
or dentures, endodontics, oral
surgery *
Major Care Services Plan pays 50% Plan pays
Includes crowns, inlays, dentures, 50% of R&C after
dental implants deductible
Orthodontic services Plan pays 50% Plan pays
coverage for dependents to age 19 50% of R&C
Maximum lifetime orthodontia $1,750 per person $1,500 per person
beneit
* Please note: oral surgery beneits apply to your calendar year maximum
Dental Rates as of January 1, 2016
Dental Plan Monthly Employee Contribution
Employee (Ee) $10.55
Ee + spouse $22.15
Ee + child(ren) $18.98
Family $33.74
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