Page 12 - 2015/2016 Benefits Guide
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Dental Plan Highlights
Premium Basic
Diagnostic and Preventative Beneits
Routine exams and bitewing x-rays twice per calendar year No deductible No deductible
Complete full mouth x-rays once in 36 months 100% 100%
Dental prophylaxis (cleaning) twice per calendar year
Topical luoride applications (under age 17) once per calendar
year
Space maintainers (under age 16)
Emergency treatment for relief of pain
Sealants (under age 14)
Basic Restorative Beneits
Amalgam, synthetic porcelain and plastic restorations (illings) $50 deductible/employee $100 deductible/employee
Periodontics $150 deductible/family $300 deductible/family
Endodontics include: pulpal therapy and root canal illing, oral 80% 70%
surgery, including extractions provided in a dentist’s ofice
Root Planing
Major Restorative and Prosthetic Beneits
(Paid only after individual is covered in this plan for 12 months)
Cast metal restorations $50 deductible/employee $100 deductible/employee
Crowns and jackets $150 deductible/family $300 deductible/family
Prosthetics: bridges, dentures, and denture repair 50% 50%
Maximum Beneit per Beneit Year
$1,200 $800
Orthodontic Beneits
Treatment necessary for the proper alignment of teeth for No deductible No coverage
dependent children under age 19 50%
Maximum lifetime orthodontic beneit $1,000
7/1/15 to 6/30/16 Dental Plans
Semi-Monthly Premium
Premium Basic
Employee only $5.31 $3.57
Employee + spouse $22.28 $15.01
Employee + child(ren) $14.32 $10.31
Employee + family $30.55 $22.88
TheBANK of Edwardsville
Dental Plan Highlights
Premium Basic
Diagnostic and Preventative Beneits
Routine exams and bitewing x-rays twice per calendar year No deductible No deductible
Complete full mouth x-rays once in 36 months 100% 100%
Dental prophylaxis (cleaning) twice per calendar year
Topical luoride applications (under age 17) once per calendar
year
Space maintainers (under age 16)
Emergency treatment for relief of pain
Sealants (under age 14)
Basic Restorative Beneits
Amalgam, synthetic porcelain and plastic restorations (illings) $50 deductible/employee $100 deductible/employee
Periodontics $150 deductible/family $300 deductible/family
Endodontics include: pulpal therapy and root canal illing, oral 80% 70%
surgery, including extractions provided in a dentist’s ofice
Root Planing
Major Restorative and Prosthetic Beneits
(Paid only after individual is covered in this plan for 12 months)
Cast metal restorations $50 deductible/employee $100 deductible/employee
Crowns and jackets $150 deductible/family $300 deductible/family
Prosthetics: bridges, dentures, and denture repair 50% 50%
Maximum Beneit per Beneit Year
$1,200 $800
Orthodontic Beneits
Treatment necessary for the proper alignment of teeth for No deductible No coverage
dependent children under age 19 50%
Maximum lifetime orthodontic beneit $1,000
7/1/15 to 6/30/16 Dental Plans
Semi-Monthly Premium
Premium Basic
Employee only $5.31 $3.57
Employee + spouse $22.28 $15.01
Employee + child(ren) $14.32 $10.31
Employee + family $30.55 $22.88
TheBANK of Edwardsville
