Dental
Dental coverage is administered through Delta Dental.
With your dental benefit program, you can go to any licensed dentist. However, you will save the most money by visiting a dentist in the Delta Dental PPO or the Delta Dental Premier network. Out-of-network dentists have not agreed to accept Delta Dental’s fees, which means they may bill for any charges over the allowed amount.
You can choose between two dental plans, the Base Plan or the Buy-Up Plan.
Buy-Up Plan includes:
- $2,500 annual maximum
- Orthodontics benefits with a $2,500 lifetime maximum
- To Go Carryover Feature – If you have a dental service that applies to your annual maximum during the benefits plan year, To Go allows unused annual maximum dollars to be applied to your dental plan for the next year — up to twice the amount of your plan’s annual maximum. Plus, your To Go carryover balance never expires, so you keep the additional dollars until you need them.
Dental Benefits
| Benefit | Delta Dental PPO* Delta Dental Premier** In-Network Base Plan |
Delta Dental PPO* Delta Dental Premier** In-Network Buy-Up Plan |
Out-of-Network *** |
|||
|---|---|---|---|---|---|---|
| Annual Deductible (Individual/Family) | $50 /$150 | $50 /$150 | $50 /$150 | |||
| Annual Maximum | $1,500/person | $2,500/person | Base Plan: $1,500/person Buy-Up Plan: $2,500/person | |||
|
Diagnostic and Preventive Care: Includes cleanings, fluoride treatments, sealants and x-rays |
100% | 100% | 100% | |||
|
Basic Services: Includes fillings, periodontics, scaling and root planning, and oral surgery |
80% | 80% | 80% | |||
|
Major Services: Includes crowns, bridges and full and partial dentures |
50% | 50% | 50% | |||
|
Orthodontics: Dependent Children to Age 19, Adults are eligible for coverage |
N/A | 50% | Buy-Up Plan: 50% | |||
| Lifetime Orthodontic Maximum | N/A | $2,500 | Buy-Up Plan: $2,500 | |||
|
To Go Carryover Feature: Allows you and your covered dependents to carry over qualified unused portions of your annual maximum from one year to the next – up to 2X your annual maximum |
N/A | Up to $5,000 (2X annual maximum) |
Buy-Up Plan: Up to $5,000 (2X annual maximum) | |||
* Delta Dental PPO dentists accept payment based on Delta’s maximum allowed fees. This is usually the highest discount available to members.
** Delta Dental Premier dentists accept payment based on a higher maximum of allowed fees. Members may pay more out of pocket.
*** Out-of-network dentists do not accept payment based on Delta’s maximum allowed fees. Members are responsible for any balance billing.
Delta Dental PPO and Premier dentists cannot balance bill members for the difference between Delta’s allowed fee and the submitted charge.
Employee Contributions
| Bi-Weekly Dental Contributions | Base | Buy-Up |
|---|---|---|
| Employee | $3.69 | $9.23 |
| Family | $11.54 | $25.38 |
Delta Dental Highlight Summary – Buy-Up Plan
Delta Dental Highlight Summary – Base Plan
20397 Alfred Benesch Company Enrollment Kit
