Applied Technology Group - 2021 Employee Benefits Guide FINAL
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DENTAL INSURANCE<br />
CARRIER: Delta Dental<br />
● You will pay less out of pocket when you choose an in-network provider.<br />
● Locate an in-network provider at www.deltadentalar.com.<br />
● Be sure to ask for a pre-treatment estimate.<br />
● Out-of-network providers can balance bill, or bill you for the difference between<br />
the provider’s charge and the allowed amount.<br />
DENTAL<br />
ELECTION<br />
SEMI-MONTHLY<br />
COST (24)<br />
<strong>Employee</strong> Only $2.69<br />
<strong>Employee</strong> & Spouse $20.33<br />
<strong>Employee</strong> & Child(ren) $19.98<br />
<strong>Employee</strong> & Family $40.85<br />
Deductible (per calendar year)<br />
COVERED BENEFITS<br />
PLAN PAYS<br />
$50 per person, 3 per family<br />
Annual Plan Benefit Maximum<br />
Preventive Care<br />
Oral exams, cleanings, X-rays, sealants<br />
Basic Services<br />
Fillings, oral surgery, root canal, simple extractions, space maintainers<br />
Major Services<br />
Periodontics, crowns, inlays, onlays, prosthodontics<br />
$1,000 per covered member<br />
100%<br />
80%<br />
50%<br />
Carryover Benefit $250<br />
Annual Maximum Carryover $1,000<br />
16
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