PG. 12
DENTAL
You have two dental plans to choose from, both administered by Delta Dental. You’ll save the most money – you won’t have to file claims yourself – if you see a Delta Dental provider.
Dental Benefits
Standard Plan
Maximum Plan
Diagnostic and Preventive Services Oral exams and routine cleaning (two per year), x-rays (one bitewing per year, one full mouth every three years), and fluoride treatments (two per year, to age 19) Basic Services Oral surgery, anesthesia, fillings, extractions, endodontia and periodontia
Plan pays 100%*
Plan pays 100%*
Plan pays 50%
Plan pays 80%
Major Services and Orthodontia* Crowns, cast restorations, fixed bridgework, dentures and orthodontia (to age 19)
Plan pays 50%
Plan pays 50%
Annual Benefit Maximum
$1,500
$2,000
Orthodontia Lifetime Maximum
$1,500
$2,000
Your Weekly Payroll Deduction
Standard Plan
Maximum Plan
Associate Only
$3.75
$5.95
Associate + Spouse
$8.40
$13.35
Associate + Child(ren)
$9.20
$14.40
Family
$12.65
$17.65
*New enrollees will be subject to a 12-month waiting period for major services and orthodontia. See Summary Plan Description (SPD) for further details.
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