Page 11 - 2018 BH Management Guide
P. 11
BH Management Services, LLC
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 Find an In-Network
Calendar Year Deductible
Individual $25 $50 Provider
Family $50 $100 Remember to visit in-network dentists to
Calendar Year Maximum $1,500 $1,500 receive the deepest level of discount on
Coinsurance your services.
Preventive 100% no deductible To ind a participating in-network
Basic** 90% after deductible 80% after deductible dentist in your area go to
Major** 50% after deductible www.deltadentalia.com or call
Orthodontia** 800.544.0718.
Coinsurance 50% no deductible
Lifetime Maximum* $1,500 Examples of Services
Beneit Applies to Adults and children Preventive—exams, cleanings, luoride,
x-rays, sealants
Orthodontia Lifetime Maximum*
Basic—illings, extractions, repairs, and
The lifetime maximum illustrated is different from the calendar year simple oral surgery
maximum. For orthodontia services, this limit does not reset each year,
this is the most your plan will cover for your services for the lifetime of Major—endodontics, periodontics,
complex oral surgery, crowns, inlays, and
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 and have a waiting period that applies. This
what is communicated in your SPD, the terms of your SPD will prevail. means that you must be enrolled in the
plan for a set amount of time in order
Contributions for the procedure to be covered by
Monthly Per Pay Period insurance.
Employee $22.00 $11.00 6 consecutive months—root canals
Employee and Spouse $45.00 $22.50 and high cost restorations
Employee and Child $45.00 $22.50
Family $75.00 $37.50 12 consecutive months—complex oral
surgery, periodontal services, bridges
and prosthetics, bridge and denture
repairs, and orthodontics
24 consecutive months—dentures
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 Find an In-Network
Calendar Year Deductible
Individual $25 $50 Provider
Family $50 $100 Remember to visit in-network dentists to
Calendar Year Maximum $1,500 $1,500 receive the deepest level of discount on
Coinsurance your services.
Preventive 100% no deductible To ind a participating in-network
Basic** 90% after deductible 80% after deductible dentist in your area go to
Major** 50% after deductible www.deltadentalia.com or call
Orthodontia** 800.544.0718.
Coinsurance 50% no deductible
Lifetime Maximum* $1,500 Examples of Services
Beneit Applies to Adults and children Preventive—exams, cleanings, luoride,
x-rays, sealants
Orthodontia Lifetime Maximum*
Basic—illings, extractions, repairs, and
The lifetime maximum illustrated is different from the calendar year simple oral surgery
maximum. For orthodontia services, this limit does not reset each year,
this is the most your plan will cover for your services for the lifetime of Major—endodontics, periodontics,
complex oral surgery, crowns, inlays, and
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 and have a waiting period that applies. This
what is communicated in your SPD, the terms of your SPD will prevail. means that you must be enrolled in the
plan for a set amount of time in order
Contributions for the procedure to be covered by
Monthly Per Pay Period insurance.
Employee $22.00 $11.00 6 consecutive months—root canals
Employee and Spouse $45.00 $22.50 and high cost restorations
Employee and Child $45.00 $22.50
Family $75.00 $37.50 12 consecutive months—complex oral
surgery, periodontal services, bridges
and prosthetics, bridge and denture
repairs, and orthodontics
24 consecutive months—dentures
11
