BHT Investment - 2022 Employee Benefit Guide

DENTAL INSURANCE
CARRIER: Delta Dental
● You will pay less out of pocket when you choose an in-network provider.
● Locate an in-network provider at www.deltadentalar.com.
● Be sure to ask for a pre-treatment estimate.
● Out-of-network providers can balance bill, or bill you for the difference
between the provider’s charge and the allowed amount.
DENTAL
ELECTION
MONTHLY
PREMIUM
WEEKLY
PREMIUM
Employee Only $27.16 $6.27
EE & Spouse $54.26 $12.52
EE & Child(ren) $67.96 $15.68
EE & Family $100.88 $23.28
COVERED BENEFITS IN-NETWORK OUT-OF-NETWORK
Deductible (per calendar year) $50 per person, $150 per family $50 per person, $150 per family
Annual Plan Benefit Maximum $1,000 per covered member $1,000 per covered member
Preventive Care
Exams, cleanings, fluoride, x-rays, sealants
Basic Services
Simple extractions, space maintainers, oral surgery, fillings
Major Services
Crowns, inlays, onlays, veneers, bridges, dentures, implants
100% 90%
80% 72%
50% 45%
Orthodontia Services (to age 19) 50% 45%
Lifetime Orthodontia Plan Max $1,000 $1,000
Annual Maximum Carryover* $250 max $1,000 max
*Carryover Eligibility: Must received at least one covered dental service and claims not to exceed $499 per year.
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