AtlantiCare 2022 Benefits Booklet

Dental

TABLE OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 SERVICE CENTERS AND WEBSITES..........4 HOW TO ENROLL....5-6 MEDICAL..............7-13 PRESCRIPTION DRUG. ................14-16 ADDITIONAL MEDICAL PLAN RESOURCES........17-22 DENTAL...............24-25 VISION.....................26 LIFECENTER..............27 LIFE INSURANCE. .....28 DISABILITY...............29 VOLUNTARY OFFERINGS. ........30-33 SPENDING ACCOUNTS. ............34 RETIREMENT BENEFITS..................35 WELLNESS. .........36-39 LEGAL NOTICES...40-42 GLOSSARY..........43-44 FAQs...................45-47 CONTACTS.........48-49 FORMS................50-56

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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