Page 11 - 2020 BH Management Benefits Guide
P. 11
Dental Coverage Delta Dental of Iowa
We partner with Delta Dental of Iowa to offer you and your family Group #92231
members dental insurance. Visit www.deltadentalia.com to ind in- www.deltadentalia.com
network providers and access a variety of online tools and programs. 800.544.0718
In-Network PPO Premier/Out-of-
Network
Calendar Year Deductible Find an In-Network
Individual $25 $50 Provider
Family $50 $100
Calendar Year Maximum Remember to visit in-network dentists to
receive the deepest level of discount on
$1,500 $1,500 your services.
Coinsurance
Preventive 0% no deductible To ind a participating in-network
Basic 10% after deductible 20% after deductible dentist in your area, go to
Major 50% after deductible www.deltadentalia.com or call
800.544.0718.
Orthodontia
Coinsurance 50% no deductible Examples of Services
Lifetime Maximum $1,500
Beneit Applies to Adults and children Preventive—exams, cleanings, luoride,
x-rays, sealants
Orthodontia Lifetime Maximum Basic—illings, extractions, repairs, and
simple oral surgery
The lifetime maximum illustrated is different from the calendar year
maximum. For orthodontia services, this limit does not reset each Major—endodontics, periodontics,
year, this is the most your plan will cover for your services for the complex oral surgery, crowns, inlays, and
lifetime of your participation in this program. dentures
This is a high level summary of your beneit coverage. Full coverage Waiting Periods
details are available in your summary plan description (SPD). In the Please remember that certain procedures
event there is a discrepancy between what is relected in this guide have a waiting period that applies. This
and what is communicated in your SPD, the terms of your SPD means that you must be enrolled in the
plan for a set amount of time in order for
will prevail. the procedure to be covered by insurance.
Contributions 6 consecutive months—root canals and
Monthly Per Pay Period high cost restorations.
Employee $21.00 $10.50
Employee and Spouse $44.00 $22.00 12 consecutive months—complex oral
surgery, periodontal services, bridges and
Employee and Child $44.00 $22.00 prosthetics, bridge and denture repairs,
Family $67.00 $33.50 and orthodontics.
24 consecutive months—dentures.
2020 Benefits Guide 11
We partner with Delta Dental of Iowa to offer you and your family Group #92231
members dental insurance. Visit www.deltadentalia.com to ind in- www.deltadentalia.com
network providers and access a variety of online tools and programs. 800.544.0718
In-Network PPO Premier/Out-of-
Network
Calendar Year Deductible Find an In-Network
Individual $25 $50 Provider
Family $50 $100
Calendar Year Maximum Remember to visit in-network dentists to
receive the deepest level of discount on
$1,500 $1,500 your services.
Coinsurance
Preventive 0% no deductible To ind a participating in-network
Basic 10% after deductible 20% after deductible dentist in your area, go to
Major 50% after deductible www.deltadentalia.com or call
800.544.0718.
Orthodontia
Coinsurance 50% no deductible Examples of Services
Lifetime Maximum $1,500
Beneit Applies to Adults and children Preventive—exams, cleanings, luoride,
x-rays, sealants
Orthodontia Lifetime Maximum Basic—illings, extractions, repairs, and
simple oral surgery
The lifetime maximum illustrated is different from the calendar year
maximum. For orthodontia services, this limit does not reset each Major—endodontics, periodontics,
year, this is the most your plan will cover for your services for the complex oral surgery, crowns, inlays, and
lifetime of your participation in this program. dentures
This is a high level summary of your beneit coverage. Full coverage Waiting Periods
details are available in your summary plan description (SPD). In the Please remember that certain procedures
event there is a discrepancy between what is relected in this guide have a waiting period that applies. This
and what is communicated in your SPD, the terms of your SPD means that you must be enrolled in the
plan for a set amount of time in order for
will prevail. the procedure to be covered by insurance.
Contributions 6 consecutive months—root canals and
Monthly Per Pay Period high cost restorations.
Employee $21.00 $10.50
Employee and Spouse $44.00 $22.00 12 consecutive months—complex oral
surgery, periodontal services, bridges and
Employee and Child $44.00 $22.00 prosthetics, bridge and denture repairs,
Family $67.00 $33.50 and orthodontics.
24 consecutive months—dentures.
2020 Benefits Guide 11
