Page 16 - 2018-19 MYNEXUS Benefits Guide
P. 16
2018–19 BENEFITS ENROLLMENT
Find an In-Network DENTAL COVERAGE
Provider Access to good oral healthcare can help keep your overall health costs down.
Remember to visit in-network Regular oral health exams can help detect significant medical conditions
(Delta Dental PPO or Delta before they become serious. For these reasons, and many others, we offer
Premier) dentists to receive the dental insurance to our employees through Delta Dental of Tennessee. Delta
deepest level of discount on Dental offers a comprehensive network within and outside of Tennessee; 4 out
your services. Delta PPO dentists
have agreed to provide discounts of 5 dentists are in the Delta Dental PPO network.
from 20% to 30%; Delta Premier Delta Dental of Delta PPO and
from 5% to 10%. Out-of-network Tennessee Delta Premier Out-of-Network
dentists will be reimbursed at Calendar Year Deductible
Delta Dental’s maximum allowable Individual $50 $50
charge which is equivalent to
the 51st percentile of usual and Family $150 $150
customary fees and may balance- Calendar Year Maximum
bill you for the diference between $1,250 $1,250
billed and allowed charges. Coinsurance
To ind a participating in-network Preventive 100% no deductible 100% no deductible*
dentist in your area go to Basic 80% after deductible 80% after deductible*
deltadentaltn.com. Major 50% after deductible 50% after deductible*
Orthodontia
Orthodontia Services Coinsurance 50% after deductible 50% after deductible
Note Lifetime Maximum $1,000 $1,000
The lifetime maximum illustrated Benefit Applies to Members up to age 19 Members up to age 19
is diferent from the calendar
year maximum. For orthodontia This is a high level summary of your benefit coverage. Full coverage details are
services, this limit does not reset available in your summary plan description (SPD). In the event there is a discrepancy
each year. This is the most your between what is reflected in this guide and what is communicated in your SPD, the
terms of your SPD will prevail.
plan will cover for your dependent
child’s services for the lifetime of Pre-Tax Bi-Weekly Contributions
your participation in this program. Employee $7.62
Examples of Services Employee and Spouse $15.86
Employee and Child(ren)
Preventive—exams, cleanings, Family $17.00
luoride, and x-rays $28.14
Basic—illings, sealants, * See out-of-network reimbursements information provided in the column on the left.
extractions, periodontics,
repairs, and oral surgery
Major—crowns, inlays,
dentures, dental impacts
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Find an In-Network DENTAL COVERAGE
Provider Access to good oral healthcare can help keep your overall health costs down.
Remember to visit in-network Regular oral health exams can help detect significant medical conditions
(Delta Dental PPO or Delta before they become serious. For these reasons, and many others, we offer
Premier) dentists to receive the dental insurance to our employees through Delta Dental of Tennessee. Delta
deepest level of discount on Dental offers a comprehensive network within and outside of Tennessee; 4 out
your services. Delta PPO dentists
have agreed to provide discounts of 5 dentists are in the Delta Dental PPO network.
from 20% to 30%; Delta Premier Delta Dental of Delta PPO and
from 5% to 10%. Out-of-network Tennessee Delta Premier Out-of-Network
dentists will be reimbursed at Calendar Year Deductible
Delta Dental’s maximum allowable Individual $50 $50
charge which is equivalent to
the 51st percentile of usual and Family $150 $150
customary fees and may balance- Calendar Year Maximum
bill you for the diference between $1,250 $1,250
billed and allowed charges. Coinsurance
To ind a participating in-network Preventive 100% no deductible 100% no deductible*
dentist in your area go to Basic 80% after deductible 80% after deductible*
deltadentaltn.com. Major 50% after deductible 50% after deductible*
Orthodontia
Orthodontia Services Coinsurance 50% after deductible 50% after deductible
Note Lifetime Maximum $1,000 $1,000
The lifetime maximum illustrated Benefit Applies to Members up to age 19 Members up to age 19
is diferent from the calendar
year maximum. For orthodontia This is a high level summary of your benefit coverage. Full coverage details are
services, this limit does not reset available in your summary plan description (SPD). In the event there is a discrepancy
each year. This is the most your between what is reflected in this guide and what is communicated in your SPD, the
terms of your SPD will prevail.
plan will cover for your dependent
child’s services for the lifetime of Pre-Tax Bi-Weekly Contributions
your participation in this program. Employee $7.62
Examples of Services Employee and Spouse $15.86
Employee and Child(ren)
Preventive—exams, cleanings, Family $17.00
luoride, and x-rays $28.14
Basic—illings, sealants, * See out-of-network reimbursements information provided in the column on the left.
extractions, periodontics,
repairs, and oral surgery
Major—crowns, inlays,
dentures, dental impacts
16
