Plan
Details
Dental
coverage underwritten by Delta Dental Insurance Company
Dental
Insurance Policy Benefits
Two
plans to choose from: Indemnity or PPO
- Free choice of dentist
- Benefits up to $1200 per calendar year
- 6 month waiting period basic
- 12 month waiting period for major and
ortho
- Benefits increase after the first and second
years
- $100 lifetime deductible on ortho
- Ortho benefits for dependents included
at no extra charge
- Keep your dental plan regardless of age
Benefit
Schedule |
| Your
Deductible |
Plan
Pays
(1st Year) |
Plan
Pays
(2nd Year) |
Plan
Pays
(3rd Year) |
Services
Covered |
| $50
per person
per calendar year |
80% |
90% |
100% |
Diagnostic
and Preventative Treatment
Diagnostic:
Routine periodic examinations once in a 6 month
period.
Preventive: Dental prophylaxis (teeth
cleaning) once in a 6 month period.
Radiography: Bitewing and full mouth
x-rays. |
| 60% |
70% |
80% |
Basic
Procedure (6 month waiting period)
Restorative:
Amalgam fillings.
Other: Space maintainers, recementation
of crowns.
|
| 0% |
40% |
50% |
Major
Procedures (12 month waiting period)
Endodontics:
Pulpal therapy and root canals.
Periodontics: Treatment of diseases
of the gums.
Oral Surgery: Extractions and other
oral surgery, including pre and post operative care.
Prosthetics: Gold restorations, crowns,
bridges, partials and complete dentures.
Other: Pontics, repair of crowns and
bridges, repair of full and partial dentures.
|
| $100
lifetime |
0% |
40% |
50% |
Orthodontia
Procedures (12 months waiting period)
($350
calendar year maximum) ($1000 lifetime maximum per person
for this benefit) Orthodontic benefits are only available
for eligible dependent children. |
Optional
Services
Services that are
more expensive than the form of treatment customarily provided
under accepted dental practice standards are called "Optional
Services." Optional Services also include the use of
specialized techniques instead of standard procedures. For
example:
(a) a crown where
a filling would restore the tooth;
(b) a precision
denture/partial where a standard denture/partial could be
used;
(c) an inlay/onlay
instead of an amalgam restoration;
(d) a composite/resin
restoration instead of an amalgam restoration on posterior
teeth.
If a member receives
Optional Services, your Benefits will be based on the lower
cost of the customary service or standard practice instead
of the higher cost of the Optional Service. Member will be
responsible for the difference between the higher cost of
the Optional Service and the lower cost of the customary service
or standard practice.
Premier TMcoverage
rates are based on Delta Dental’s Premier network.
Both Premier and Non-Delta Dental dentists are reimbursed
on Usual, Reasonable and Customary (UCR) charges. The
Premier dentist will file the claim with Delta Dental
and will not balance bill. Click
here to locate Premier Providers... |
PPO
coverage rates are based on Delta Dental’s PPO
network. Benefits for all dentists are based on Delta
Dental’s reduced PPO fee schedule. PPO dentists
wil file the claim with Delta Dental. There is no balance
billing for PPO dentists.
Click
here to locate PPO Providers... |
Monthly
Rates |
Premier
Rates
| Area |
Member |
Plus
One |
Family |
1 |
$36.64 |
$66.70 |
$96.76 |
2 |
$40.12 |
$73.48 |
$106.85 |
3 |
$43.98 |
$81.02 |
$118.05 |
4 |
$48.27 |
$89.38 |
$130.49 |
5 |
$53.03 |
$98.66 |
$144.29 |
6 |
$58.32 |
$108.96 |
$158.61 |
7 |
$64.18 |
$120.40 |
$176.62 |
Includes:
$4.00 Billing Fee, $1.00 Association Dues,
and 4% Administration Fee
|
PPO
Rates
| Area |
Member |
Plus
One |
Family |
1 |
$29.68 |
$53.12 |
$76.57 |
2 |
$32.39 |
$58.42 |
$84.44 |
3 |
$35.41 |
$64.29 |
$93.18 |
4 |
$38.75 |
$70.82 |
$102.88 |
5 |
$42.46 |
$78.06 |
$113.65 |
6 |
$46.59 |
$86.09 |
$125.60 |
7 |
$51.16 |
$95.01 |
$138.86 |
8 |
$56.24 |
$104.91 |
$153.59 |
Includes:
$4.00 Billing Fee, $1.00 Association Dues,
and 4% Administration Fee
|
Find Your Area:
Click here to view the Indemnity Area Chart
|
Find Your Area:
Click here to view the PPO Area Chart
|
Dental
Plan Exclusions
Delta
Dental does not pay Benefits for:
a) Services
for injuries or conditions which are compensable under workers'
compensation or employers' liability laws; services which
are provided to the Enrollee by any federal or state government
agency or are provided without cost to the Enrollee by any
municipality, county or other political subdivision except
as such exclusion may be prohibited by law.
b) Services
with respect to congenital (hereditary) or developmental (following
birth) malformations or cosmetic surgery or dentistry for
purely cosmetic reasons, including but not limited to cleft
palate, maxillary and mandibular (upper and lower jaw) malformations,
enamel hypoplasia (lack of development), fluorosis (a type
of discoloration) of the teeth, and andontia (congenitally
missing teeth), except those services provided to newborn
children for congenital defect or birth abnormalities or services
that may be provided under Orthodontic Benefits.
c) Services
for restoring tooth structure lost from wear, erosion, or
abrasion, for rebuilding or maintaining chewing surfaces due
to teeth out of alignment or occlusion, or for stabilizing
the teeth. Such services include, but are not limited to:
equilibration, periodontal splinting, occlusal adjustment.
d) Any
Single Procedure started prior to the date the person became
covered for such services under this program.
e) Prescribed
drugs, medication or analgesia.
f) Experimental
procedures.
g) Charges
by any hospital or other surgical or treatment facility and
any additional fees charged by the Dentist for treatment in
any such facility.
h) Charges
for anesthesia, other than by a licensed Dentist for administering
general anesthesia in connection with covered oral surgery
services.
i) Extra
oral grafts (grafting of tissues from outside the mouth to
oral tissues).
j) Services
with respect to any disturbance of the temporomandibular joint
(jaw joint).
k) Services
performed by any person other than a Dentist or auxiliary
personnel legally authorized to perform services under the
direct supervision of a Dentist.
l) Replacement
of teeth extracted prior to the member's effective date.
The preceding information is a brief description of coverage.
Contact Benefits Association for complete details.
Online
Enrollment
You may purchase
the Dental for Everyone plan in two ways:
-
Buy it right
now by selecting our Premier
Plan or our PPO
Plan. After clicking this link, you will be prompted
to enter your zip code. This will begin the enrollment
process.
- Download an
application from our Forms section.
Vision
Benefits
-
No
deductible
-
No
waiting period
-
A
vision examination each 12 months
-
One
set of frames each 24 months
-
Your
choice of eye care providers
-
One
pair of standard lenses or contact lenses each 12
months
-
In-
and Out-of-Network benefits
-
Laser
eye surgery benefits through the Laser Vision Network
of America (LVNA)
-
Network
Providers include Private Practice Doctors and Retail
Chain Providers
Monthly
Vision Premiums
Area |
Member |
Plus
One |
Family |
4 |
$9.88 |
$17.12 |
$28.88 |
Vision Rate Areas
|
In-Network
Benefits
• Lenses: If prescribed, a pair of single vision
or standard lined multi-focal lenses every 12 months with
only a $20.00 co-pay
• In lieu of lenses and a frame, ($20.00 co-payment
applies) you may select from Spectera’s wide variety
of covered contact lenses when obtained from a network
provider. A $105.00 credit will be applied toward any fitting
fees, and the purchase of non-covered contact lenses once
every 12 months.
• There is a $210 allowance for “necessary”
contacts. (When your vision cannot be corrected to better
than 70/20 with standard lenses.)
• One pair of frames (each 24 months) from a wide
selection of high quality men’s, women’s and
children’s frames and a set of lined single/bifocal/trifocal
lenses (each 12 months) for a $20.00 co-pay. If you select
a frame from outside the covered selection, you will pay
the wholesale cost minus a $50.00 frame allowance. In the
case of retail chain provider locations, due to their pricing
structures, the participant will receive a minimum $130
frame allowance for frames purchased at retail chain providers.
Please consult with the specific provider in your area.
• Patient Options: Should you select items not covered
by the program, such as progressive lenses, tints, coatings,
ect., there will be an additional charge. These charges,
however, are below usual retail costs. (Standard Scratch
coating is covered in full at no cost to the insured.)
• To locate an In-Network Provider call 800-839-3242
or use Spectera’s web site www.spectera.com (Click
on provider locator, enter zip code, enter social security
number or [any 9 digit number], enter birth date and click
submit.)
Out-of-Network
Benefits
(Out-of-Network
– Reimbursement up to the following amounts once
in a 12-month period – frames once in a 24-month
period)
Important
Information About Out-of-Network Benefits
Spectera
will accept receipts and reimburse you once each
12 months (frames each 24 months) (from date
of service) when you use an “out -of-network” provider.
While you can file for reimbursement anytime
after you receive your exam and eyewear, in order
to maximize your “out-of-network”
benefits, itemized receipts should be collected
(i.e. several purchases of contact lenses) until
they total (at least) the maximum reimbursement
amounts. Be sure to include with the receipts the
participant’s social security number and
patient’s date of birth. MAIL TO:
Spectera
P.O. Box 26618
Baltimore, MD 21207-6618
When
scheduling your appointment, be sure to say that
you are covered under the MorganWhiteGroup / Spectera
Vision Plan so that the provider can confirm your
eligibility and benefits prior to the appointment. |
| Annual
Vision Examination |
$40.00 |
| Single
Vision Lenses |
$40.00 |
| Bifocal |
$60.00 |
| Trifocal |
$80.00 |
| Frames |
$50.00 |
| Elective
Contacts |
$105.00 |
| Necessary
Contacts |
$210.00 |
