Page 15 - GESMN 2019 Benefits Enrollment Guide

Dental – The Standard

Dental Benefits New carrier in 2019!

Eligible employees working 20 or more hours per week have the choice of two options To Find a Dentist in
under The Standard. Similar to medical insurance, you will almost always pay less if you the Standard
visit an in-network dentist or specialist. In-network dentists agree to charge a negotiated Network
rate. When you see an out-of-network provider, the plan will pay based on the 90th
• Go to
percentile of usual and customary. A charge is considered “customary” if it is within a standard.com/
range of fees that most dentists in the area charge for a given procedure. For your dental
pocketbook, it pays to stay in-network. And your participating dentist will submit claims • Type in your ZIP Code
and make sure to
for you! To locate an in-network provider, visit www.standard.com/dental select “Classic PPO”
With the change to The Standard please contact your provider and verify that they
are in-network with The Standard.
If you enroll in dental with The Standard, you will receive dental cards which you
should provide to your dentist to ensure they have proper claim information for 2019.

Dental Benefits At-a-Glance
2019 Dental Plan Premiums Low Plan High Plan

In-Network In-Network
Annual Deductible $50/person $50/person
Waived for Type 1 Waived for Type 1
(preventive) services (preventive) services
Annual Plan Maximum $1,000 $1,500
Lifetime Orthodontia Plan Maximum (child) No coverage $1,500
Type 1: Plan pays 100% Plan pays 100%
Exams, Cleanings, Sealants, X-rays
Type 2: Plan pays 80% Plan pays 80%
Amalgam Fillings, Restorative
Composites, Endodontics, and Simple
Extractions
Type 3: Plan pays 50% Plan pays 50%
Periodontal Surgery, Crowns, Dentures,
Bridges, Implants
Orthodontia (available for children up to No coverage Plan pays 50%
age 19)

Please note: The difference between the two plans is that the high plan offers a higher
annual benefit plan maximum — $1,500 versus $1,000 and an orthodontia benefit for
dependent children.

2019 Dental Plan Premiums

Low Plan High Plan
Bi-Weekly Bi-Weekly
Employee $11.50 $14.68
Employee + 1 $24.09 $30.76
Family $39.53 $50.47 15