AtlantiCare Benefits Book 2020

Dental

HOME TABL OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 I E CENTERS AND EBSITES...................4 HO TO ENROLL.......5 MEDICAL..............6-12 PRESCRIPTION DRUG. ................13-15 ADDITIONAL MEDICAL PLAN RESOURCES.........16-18 DENTAL...............19-21 VISION.....................22 LIFECENTER..............23 LIFE INSURANCE. .....24 LONG TERM DISABILITY...............25 VOLUNTARY OFFERINGS. ........26-29 SPENDING ACCOU TS. ............30 RETIREMENT B NEFITS..................31 WELLNESS. .........32-36 LEGAL NOTICES..37-39 CONTACTS.........40-41 GLOSSARY..........42-43 FAQs...................44-46 FORMS................47-56 WHAT’S NEW SERVICE CENTERS AND WEBSITES HOW TO ENROLL MEDICAL PRESCRIPTION DRUG ADDITIONAL MEDICAL PLAN RESOURCES DENTAL VISION LIFE INSURANCE LONG TERM DISABILITY VOLUNTARY OFFERINGS SPENDING ACCOUNTS RETIREMENT BENEFITS WELLNESS LEGAL NOTICES CONTACTS GLOSSARY

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.

FORMS

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