AtlantiCare 2025 Benefits Booklet

DENTAL (CONT.)

Welcome.................................... 2 What’s New?............................. 3 How to Enroll........................... 4 Medical....................................... 6 Prescription Drug.................14 FQHC.........................................16 Additional Medical Plan Resources................................17 AtlantiCare Longevity Lifestyle Program................18 Dental.......................................20 Vision.........................................22 Life Insurance........................25 Disability..................................26 Voluntary Offerings.............27 Educational Support & Career Development..........27 Financial Well-being...........28 Health &Wellness................29 Savings.....................................31 Voluntary Benefits...............32 Spending Accounts.............35 Retirement Benefits............36 Contacts...................................38 Legal Notices.........................40 Wellness Checklist...............42

Summary of Dental Benefits

Dental Plus Ortho Plan*

Summary of Services

Basic Dental Plan

Preventive (routine exams, xrays, cleanings)

100%

100%

Basic Care (fillings, extractions, periodontal)

70%

90%

Major Care ( crowns, dental implants, dentures)

50%

60%

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 person

0%

Annual Maximum Per Individual

$1,500

$2,500

Annual Deductible Amount Per Person

$25

$25

Annual Deductible Amount Per Family

$75

$75

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

Bi-Weekly Employee Dental Cost

Bi-Weekly Cost

Bi-Weekly Cost

Coverage Type

For Basic

For Plus Ortho

Employee

$2.60

$9.36

Employee/Child or Employee + Spouse

$5.20

$22.88

Family

$7.80

$26.00

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