Employee Benefits Guide

Dental Insurance Plans ABC offers two dental insurance plan options through Carrier Name. With the Carrier Name Premier plan, you and your family members may visit any licensed dentist but will receive the greatest out-of-pocket savings if you see a Carrier Name dentist. Participating dentists (both PPO and Premier) file claims directly with Carrier Name and accept Carrier Name’s reimbursement in full. You are responsible only for your deductible and coinsurance (listed in the chart below), as well as any charges for non-covered services up to Delta Dental’s approved amount. If you choose to see a non-participating dentist, you will incur additional out-of-pocket expenses, and you will be billed the total amount the dentist charges (called balance-billing). When you see a Carrier Name PPO or Premier dentist, you are protected from balance-billing.

The table below summarizes the key features of the dental plans. The coinsurance amounts listed reflect the amount the member pays. Please refer to the official plan documents for additional information on coverage and exclusions.

Option I PPO Dentist

Option I Premier Dentist

Option I Non- Participating Dentist

Option II PPO Dentist

Option II Premier Dentist

Option II Non- Participating Dentist

Carrier Name Summary of Covered Benefits

Plan Year Deductible Individual/Family Plan Year Benefit Max Preventive Care Oral Evaluation (2 per p/y), Bitewing X-rays (1 set per p/y), Full Mouth X- rays (1 per 36 months), Routine Cleaning (2 per p/y), Fluoride Treatment (1 per p/y to age 16), Space Maintainers (posterior primary teeth to age 14), Sealants (1 per tooth in 36 months to age

$50/$150

$50/$150

$50/$150

$50/$150

$50/$150

$50/$150

$3,000

$3,000

$3,000

$1,000

$1,000

$1,000

0%

20%

20%

50%

50%

50%

Basic Services Fillings, Endodontics (Root Canal), Periodontics (Gum Disease), Oral Surgery Major Services Crowns, Dentures, Partials, Bridges

20% after deductible

40% after deductible

40% after deductible

50% after deductible

50% after deductible

50% after deductible

50% after deductible

60% after deductible

60% after deductible

50% after deductible

50% after deductible

50% after deductible

Implants

50%

50%

50%

50%

50%

50%

$2,000 per covered member $2,000 per covered member 50%

$2,000 per covered member $2,000 per covered member 50%

$2,000 per covered member $2,000 per covered member 50%

$1,000 per covered member Not covered

$1,000 per covered member Not covered

$1,000 per covered member Not covered

Lifetime Benefit Max

Orthodontia Services

Lifetime Benefit Max

Not covered

Not covered

Not covered

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