Page 17 - 2019 Benefits Enrollment
P. 17
DENTAL
We partner with Guardian to offer you comprehensive dental coverage.
Our dental plan makes dental care more affordable for associates and Guardian ofers a maximum rollover
feature. Here’s how it works:
their families. Keep in mind, the information in the chart provided is a
summary only. Please refer to your Certiicate of Coverage (COC) for If you incur $600 or less of dental
complete details OTL. claims during the plan year, you
are allowed a maximum rollover
amount of $300 to be added to your
Visit www.guardiananytime.com. plan maximum for future years. As
an added bonus, if you saw only
In-Network Out-of-Network in-network providers during the plan
Calendar Year Deductible year, you will receive an additional
Individual $50 $50 $150 towards your annual maximum
Family $150 $150 amount.
Coinsurance
Preventive 100% 100% Benefit Compensation
Basic 80% 80%
Major 50% 50% Bi-Weekly < $100,000 ≥ $100,000
Calendar Year Maximum Rates
$1,250 $1,250 Associate $9 .90 $11 .42
Orthodontia only
Coinsurance 50% 50% Associate + $22 .84 $25 .88
Lifetime maximum $1,500 $1,500 spouse
Beneit applies to Children under age 20 Children under age 20 Associate + $28 .39 $32 .17
Visits and Exams child(ren)
Visit for oral examination Once every 6 months Once every 6 months Family $46 .41 $52 .60
Prophylaxis, including scaling and Once every 6 months Once every 6 months For provider search information,
polishing see page 7.
Fluoride Once every 6 months Once every 6 months
Children under age 19 Children under age 19
Sealants Once every 6 months Once every 6 months
Children under age 19 Children under age 19
X-Rays
Bitewing x-rays 2 per beneit year 2 per beneit year
Full mouth x-rays Once every 60 months Once every 60 months
Endodontics
Pulpotomy Covered at 80% Covered at 80%
Apicoectomy Covered at 80% Covered at 80%
Minor Restorations
Amalgam (silver) illings Covered at 80% Covered at 80%
Composite illings (anterior teeth Covered at 80% Covered at 80%
only)
Stainless steel crowns Covered at 80% Covered at 80%
Uncomplicated extractions Covered at 80% Covered at 80%
Surgical removal of erupted tooth Covered at 80% Covered at 80%
Inlays Covered at 50% Covered at 50%
Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%
Full and partial dentures Covered at 50% Covered at 50%
Denture repairs Covered at 50% Covered at 50%
First Busey Corporation 17
We partner with Guardian to offer you comprehensive dental coverage.
Our dental plan makes dental care more affordable for associates and Guardian ofers a maximum rollover
feature. Here’s how it works:
their families. Keep in mind, the information in the chart provided is a
summary only. Please refer to your Certiicate of Coverage (COC) for If you incur $600 or less of dental
complete details OTL. claims during the plan year, you
are allowed a maximum rollover
amount of $300 to be added to your
Visit www.guardiananytime.com. plan maximum for future years. As
an added bonus, if you saw only
In-Network Out-of-Network in-network providers during the plan
Calendar Year Deductible year, you will receive an additional
Individual $50 $50 $150 towards your annual maximum
Family $150 $150 amount.
Coinsurance
Preventive 100% 100% Benefit Compensation
Basic 80% 80%
Major 50% 50% Bi-Weekly < $100,000 ≥ $100,000
Calendar Year Maximum Rates
$1,250 $1,250 Associate $9 .90 $11 .42
Orthodontia only
Coinsurance 50% 50% Associate + $22 .84 $25 .88
Lifetime maximum $1,500 $1,500 spouse
Beneit applies to Children under age 20 Children under age 20 Associate + $28 .39 $32 .17
Visits and Exams child(ren)
Visit for oral examination Once every 6 months Once every 6 months Family $46 .41 $52 .60
Prophylaxis, including scaling and Once every 6 months Once every 6 months For provider search information,
polishing see page 7.
Fluoride Once every 6 months Once every 6 months
Children under age 19 Children under age 19
Sealants Once every 6 months Once every 6 months
Children under age 19 Children under age 19
X-Rays
Bitewing x-rays 2 per beneit year 2 per beneit year
Full mouth x-rays Once every 60 months Once every 60 months
Endodontics
Pulpotomy Covered at 80% Covered at 80%
Apicoectomy Covered at 80% Covered at 80%
Minor Restorations
Amalgam (silver) illings Covered at 80% Covered at 80%
Composite illings (anterior teeth Covered at 80% Covered at 80%
only)
Stainless steel crowns Covered at 80% Covered at 80%
Uncomplicated extractions Covered at 80% Covered at 80%
Surgical removal of erupted tooth Covered at 80% Covered at 80%
Inlays Covered at 50% Covered at 50%
Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%
Full and partial dentures Covered at 50% Covered at 50%
Denture repairs Covered at 50% Covered at 50%
First Busey Corporation 17
