Page 17 - 2018 Busey Benefit Guide
P. 17
2018 BENEFITS ENROLLMENT
Dental
Our dental coverage is In-Network Out-of-Network
provided through Aetna. Our Calendar Year Deductible $50 $50
Individual
dental plan makes dental care Family $150 $150
more affordable for associates Coinsurance
and their families. We Preventive 100% 100%
80%
Basic
80%
partner with Aetna to offer Major 50% 50%
you comprehensive dental Calendar Year Maximum $1,250 $1,250
coverage options. Keep in Orthodontia
50%
50%
mind, the information in the Coinsurance $1,500 $1,500
Lifetime maximum
chart provided is a summary Beneit applies to Children under age 20 Children under age 20
only. Please refer to your Visits and Exams 2 per beneit year 2 per beneit year
Visit for oral examination
Certiicate of Coverage (COC) Prophylaxis, including scaling 2 per beneit year 2 per beneit year
for complete details on OTL. and polishing
Fluoride Once per beneit year Once per beneit year
Children under age 19
Children under age 19
All of your dental beneits Sealants Under age 16 Under age 16
have remained the same for X-Rays
the 2018 beneit year. Bitewing x-rays 2 per beneit year 2 per beneit year
Once every three
Once every three
Full mouth x-rays years years
Visit www.aetna.com. Endodontics
Pulpotomy Covered at 80% Covered at 80%
Apicoectomy Covered at 80% Covered at 80%
Minor Restorations
Amalgam (silver) illings Covered at 80% Covered at 80%
Composite illings (anterior Covered at 80% Covered at 80%
teeth only)
Stainless steel crowns Covered at 80% Covered at 80%
Uncomplicated extractions Covered at 80% Covered at 80%
Surgical removal of erupted Covered at 80% Covered at 80%
tooth
Inlays Covered at 50% Covered at 50%
Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%
Full and partial dentures Covered at 50% Covered at 50%
Denture repairs Covered at 50% Covered at 50%
Benefit Compensation
Bi-weekly Rates < $92,500 ≥ $92,500
Associate only $9.08 $10.47
Associate + spouse $20.95 $23.74
Associate + child(ren) $26.04 $29.51
Family $42.57 $48.25
FIRST BUSEY CORPORATION 17
Dental
Our dental coverage is In-Network Out-of-Network
provided through Aetna. Our Calendar Year Deductible $50 $50
Individual
dental plan makes dental care Family $150 $150
more affordable for associates Coinsurance
and their families. We Preventive 100% 100%
80%
Basic
80%
partner with Aetna to offer Major 50% 50%
you comprehensive dental Calendar Year Maximum $1,250 $1,250
coverage options. Keep in Orthodontia
50%
50%
mind, the information in the Coinsurance $1,500 $1,500
Lifetime maximum
chart provided is a summary Beneit applies to Children under age 20 Children under age 20
only. Please refer to your Visits and Exams 2 per beneit year 2 per beneit year
Visit for oral examination
Certiicate of Coverage (COC) Prophylaxis, including scaling 2 per beneit year 2 per beneit year
for complete details on OTL. and polishing
Fluoride Once per beneit year Once per beneit year
Children under age 19
Children under age 19
All of your dental beneits Sealants Under age 16 Under age 16
have remained the same for X-Rays
the 2018 beneit year. Bitewing x-rays 2 per beneit year 2 per beneit year
Once every three
Once every three
Full mouth x-rays years years
Visit www.aetna.com. Endodontics
Pulpotomy Covered at 80% Covered at 80%
Apicoectomy Covered at 80% Covered at 80%
Minor Restorations
Amalgam (silver) illings Covered at 80% Covered at 80%
Composite illings (anterior Covered at 80% Covered at 80%
teeth only)
Stainless steel crowns Covered at 80% Covered at 80%
Uncomplicated extractions Covered at 80% Covered at 80%
Surgical removal of erupted Covered at 80% Covered at 80%
tooth
Inlays Covered at 50% Covered at 50%
Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%
Full and partial dentures Covered at 50% Covered at 50%
Denture repairs Covered at 50% Covered at 50%
Benefit Compensation
Bi-weekly Rates < $92,500 ≥ $92,500
Associate only $9.08 $10.47
Associate + spouse $20.95 $23.74
Associate + child(ren) $26.04 $29.51
Family $42.57 $48.25
FIRST BUSEY CORPORATION 17
