2023 AtlantiCare Benefits Booklet

Dental

TABLE OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 SERVICE CENTERS AND WEBSITES..........4 HOW TO ENROLL....5-6 MEDICAL..............7-14 PRESCRIPTION DRUG. ................15-17 ADDITIONAL MEDICAL PLAN RESOURCES........18-22 DENTAL...............23-24 VISION.....................25 LIFECENTER..............26 LIFE INSURANCE. .....27 DISABILITY...............28 VOLUNTARY OFFERINGS. ........29-32 SPENDING ACCOUNTS. ............33 RETIREMENT BENEFITS..................34 WELLNESS. .........35-38 LEGAL NOTICES...39-41 GLOSSARY..........42-43 FAQs...................44-46 CONTACTS.........47-48 FORMS................49-58

Below is a chart that compares the benefits payable for services.

Dental Plus Ortho Plan*

Care Category

Basic Dental Plan

Diagnostic

100%

100%

X-Rays

100%

100%

Preventive

100%

100%

Restorative

70%

90%

Restorative - Crowns

50%

60%

Endodontics

70%

90%

Periodontics

70%

90%

Prosthetics Removable

50%

60%

Prosthetics Adjustment

50%

60%

Prosthetics Fixed

50%

60%

Extractions

70%

90%

General Services

70%

90%

50% $1,000 annual maximum

60% $1,500 annual maximum 60% $2,000 lifetime maximum

Implants, subject to annual maximum per patient

Orthodontics* subject to a lifetime maximum per child

0%

Annual Maximum Per Individual

$1,000

$2,000

Annual Deductible Amount Per Person

$25

$25

Annual Deductible Amount Per Family

$75

$75

*Orthodontia coverage is only available if your child was enrolled in the plan prior to the initial orthodontia appointment for braces. *You must continue to be enrolled in the “Dental Plus Ortho” plan for the entire time your dependent child requires orthodontia services as payments are on a pro-rated basis.

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