Acom 2023 Benefit Guide - Class 3 - All Other Eligible Empl…

Dental Coverage

Regular dental exams can help you and your dentist detect problems in the early stages when treatment is simpler and costs are lower.

Keeping your teeth and gums clean and healthy will prevent most tooth decay and periodontal disease, and is an important part of maintaining your medical health.

Your PPO dental plan is through Sun Life and offers “in and out-of-network” benefits.

Insurance Carrier:

Sun Life Dental Insurance

Plan Type:

Basic

Enhanced

Calendar Year Deductible Calendar Year Maximum

$50 Individual / $150 Family $50 Individual / $150 Family

$1,000

$2,000

Preventive Services

100%

100%

Basic Services Major Services

80% 50%

90% 60%

Orthodontia (dependent children only) Out-of-Network Reimbursement

N / A

$1,000

90th UCR

90th UCR

Employee Weekly Deduction Employee Only

$3.38 $7.90 $7.77

$6.90

Employee + Spouse Employee + Child(ren)

$13.28 $18.59 $23.51

Family

$11.14

time insured continuously under a dental plan benefits provided for only these services Less than 6 months Preventive Services At least 6 months but less than 12 months Preventive Services and fillings under Basic Services At least 12 months Preventive, Basic, Major and Ortho Services

9 Acom Integrated Solutions 2023 Enrollment Guide

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