Page 14 - Enrollment Guide
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Dental Coverage
Dental Coverage
Delta Dental of Tennessee is the dental plan administrator for EnTrans’s 2016 plan year. Taking care of your
mouth, teeth, and gums is a big part of making sure you feel your best. Healthy habits like brushing, lossing and
seeing your dentist for regular cleanings helps prevent problems.
Dental coverage is a voluntary beneit. Your cost for this coverage is entirely separate from our medical and
prescription drug programs. Below is a brief summary of the beneits offered to all beneits eligible employees.
Dental
Beneits Services Deductible Coinsurance Beneit Maximum
Class I Exams, cleanings, x-rays, sealants, No deductible 100% PPO, premier $2,000 maximum per
emergency treatment and out-of-network calendar year
Class II Minor restorative—illings, gum disease, $50 individual/$150 80% PPO, premier, $2,000 maximum per
root canals, extractions, oral surgery family, per calendar year and out-of-network calendar year
Class III Major restorative— crowns, bridges, $50 individual/$150 50% PPO, premier, $2,000 maximum per
dentures, implants family, per calendar year and out-of-network calendar year
Class IV Orthodontics—braces (children only) No deductible 50% PPO, premier, $1,500 lifetime
and out-of-network maximum
Your 2016 monthly dental contributions are shown below.
Delta PPO Plan
Employee $5.86
Employee + spouse $12.29
Employee + child(ren) $10.54
Family $18.73
Dental Coverage
Dental Coverage
Delta Dental of Tennessee is the dental plan administrator for EnTrans’s 2016 plan year. Taking care of your
mouth, teeth, and gums is a big part of making sure you feel your best. Healthy habits like brushing, lossing and
seeing your dentist for regular cleanings helps prevent problems.
Dental coverage is a voluntary beneit. Your cost for this coverage is entirely separate from our medical and
prescription drug programs. Below is a brief summary of the beneits offered to all beneits eligible employees.
Dental
Beneits Services Deductible Coinsurance Beneit Maximum
Class I Exams, cleanings, x-rays, sealants, No deductible 100% PPO, premier $2,000 maximum per
emergency treatment and out-of-network calendar year
Class II Minor restorative—illings, gum disease, $50 individual/$150 80% PPO, premier, $2,000 maximum per
root canals, extractions, oral surgery family, per calendar year and out-of-network calendar year
Class III Major restorative— crowns, bridges, $50 individual/$150 50% PPO, premier, $2,000 maximum per
dentures, implants family, per calendar year and out-of-network calendar year
Class IV Orthodontics—braces (children only) No deductible 50% PPO, premier, $1,500 lifetime
and out-of-network maximum
Your 2016 monthly dental contributions are shown below.
Delta PPO Plan
Employee $5.86
Employee + spouse $12.29
Employee + child(ren) $10.54
Family $18.73
