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Comprehensive Behavioral Health
9
Advantica Voluntary Dental
Benefit/Service
In-Network
Out-of-Network
Benefit
Preventive
100%
100%
Basic
80%
80%
Major
50%
50%
Ortho
50%
50%
Deductibles & Maximums
Deductible Individual *
$50
Deductible Family
$150
Annual Maximum Per Person
$1,500
Lifetime Orthodontia Maximum **
$1,500
* Does not apply to preventive services.
** Orthodontic services are available for children up to age 19.
Dental Employee Cost
2015
Employee
Monthly
Cost
Employee
$30.54
Employee & Spouse
$61.08
Employee & Child(ren)
$73.62
Employee & Family
$104.61
2015—2016 Employee Dental
Contributions
2015
Employee
Per
Paycheck
Cost
$15.27
$30.54
$36.81
$52.31
DENTAL INSURANCE
You will have coverage both in-network and out-
of-network. It is to your advantage to utilize a
network dentist to take advantage of contracted
fees. You will experience the deepest discounts
when seeing an in-network dentist. If you go out-
of-network, you will be responsible for any
amount exceeding Advantica’s negotiated rates
plus any deductible and co-insurance associated
with your procedure.
Out-of-Network Services
All out-of-network claims are paid at the 90th
Percentile of UCR. The provider will bill the
insured for any charges that exceed the 90th
Percentile of UCR. (Usual and Customary
Reimbursement)
If you enroll in the dental plan at a time other than when first
eligible you will be considered a late entrant and will only
have coverage for preventive and emergency services for the
first 12 months.