Page 12 - 2022 Drive Open Enrollment Guide - Non Union

Dental plan

It’s important to have regular dental exams and cleanings so problems are detected before they become painful —and expensive.
Keeping your teeth and gums clean and healthy will help prevent most tooth decay and is an important part of maintaining your
overall health. We offer dental through Empire.

Using in-network dental providers
While you have the option of choosing any provider, you will save money when you use in-network dentists. When using an out-of-
network dental provider, you will pay more because the provider has not agreed to charge you a negotiated rate. To search for a PPO
provider, go to www.empireblue.com and search using the “Dental Complete” network.

Low Plan High Plan
Plan Provisions
In-Network Out-of-Network In-Network Out-of-Network

Annual Deductible $100 / $300 $50 / $150
(Individual/Family)
Annual Maximum (per $1,500 $2,500
person)
Diagnostic and Preventive
Care:
Covered 100%, no Covered 100%, no Covered 100%, no Covered 100%, no
Includes cleanings (2 per
deductible deductible deductible deductible
year), fluoride treatments
and sealants
Basic Services:
Includes fillings, 20% after 20% after 20% after 20% after
periodontics, and simple deductible deductible deductible deductible
extractions

Major Services: 50% after 50% after 40% after 40% after
Includes crowns, bridges deductible deductible deductible deductible
and full and partial dentures
40% after 40% after
Orthodontia (Adult & Not Covered Not Covered deductible deductible
Children) $2,000 lifetime $2,000 lifetime
limit limit

12