Page 17 - 2017 Benefits Enrollment Busey Pulaski

2017 BENEFITS ENROLLMENT

Dental

This year, our dental coverage In-Network Out-of-Network

will be provided through Calendar Year Deductible $50 $50
Individual
Aetna. We chose to make this Family $150 $150
change to ensure the best Coinsurance
network and rates possible. Preventive 100% 100%
80%
80%
Basic
Our dental plan makes dental Major 50% 50%
care more affordable for Calendar Year Maximum $1,250 $1,250
associates and their families. Orthodontia
50%
50%
We partner with Aetna to Coinsurance $1,500 $1,500
Lifetime maximum
offer you comprehensive Beneit applies to Children under age 20 Children under age 20
dental coverage options. Keep Visits and Exams 2 per beneit year 2 per beneit year
Visit for oral examination
in mind, the information Prophylaxis, including scaling 2 per beneit year 2 per beneit year

in the chart provided is a and polishing Once per beneit year Once per beneit year
summary only. Please refer to Fluoride Children under age 19 Children under age 19
your Certiicate of Coverage Sealants Under age 16 Under age 16
(COC) for complete details on X-Rays 2 per beneit year 2 per beneit year
Bitewing x-rays
OTL. Full mouth x-rays Once every three Once every three
years
years
All of your dental beneits Endodontics Covered at 80% Covered at 80%
Pulpotomy
have either remained the Apicoectomy Covered at 80% Covered at 80%
same or increased for the Minor Restorations Covered at 80% Covered at 80%
Amalgam (silver) illings
2017 beneit year. This year, Composite illings (anterior Covered at 80% Covered at 80%
you will notice that your teeth only) Covered at 80% Covered at 80%
Stainless steel crowns
orthodontia lifetime maximum Uncomplicated extractions Covered at 80% Covered at 80%
has increased from $1,000 to Surgical removal of erupted Covered at 80% Covered at 80%
tooth
$1,500. Stainless steel crowns Inlays Covered at 50% Covered at 50%
are covered at 80 percent. Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%

Visit www.aetna.com. 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 $8.56 $9.88
Associate + spouse $19.76 $22.40
Associate + child(ren) $24.56 $27.84
Family $40.16 $45.52

FIRST BUSEY CORPORATION 17