HomeMy WebLinkAboutDelta Dental-11/12/2013Delta Dental of Iowa
Summary of Covered Services and Benefits: Altemate 2
City of Waterloo Group # 92179
Deductibles,Maximums & Eligibility
- Individual Deductible
- Family Deductible
- Deductible applies to Check -Ups and Teeth Cleaning?
- Benefit Period Maximum
- Eligible children to age
- Full-time (unmarried) students eligible to age
- Does Individual Deductible apply to Orthodontics?
- Orthodontic lifetime maximum
- Orthodontics: Eligible children to age
- Orthodontics: Full-time students eligible to age
- Adult Orthodontics
Benefits
Check -Ups and Teeth Cleaning
(Diagnostic and Preventive Services)
- Dental Cleaning
- Oral Evaluations
- Fluoride Applications
- X -Rays
- Sealant Applications
- Space Maintainers
Cavity Repair and Tooth Extractions
(Routine and Restorative Services)
- Emergency Treatment
- General Anesthesia/Sedation
- Restoration of Decayed or Fractured Teeth
- Limited Occlusal Adjustments
- Routine Oral Surgery
- Posterior Composites w/ Alternate Processing
Root Canals (Endodontic Services)
- Apicoectomy
- Direct Pulp Cap
- Pulpotomy
- Retrograde Fillings
- Root Canal Therapy
Gum and Bone Diseases (Periodontal Services)
- Conservative Procedures (Non-surgical)
- Complex Procedures (Surgical)
- Periodontal Maintenance Therapy
High Cost Restorations (Cast Restorations)
- Cast Restorations
- Crowns
- Inlays
- Onlays
- Post and Cores
- Recementing Crowns/Inlays/Onlays
Dentures and Bridges (Prosthetic Services)
- Bridges
- Dentures
- Repairs and Adjustments
- Recementing of Bridges
-Implants w/o Alternate Processing
Straighter Teeth (Orthodontics)
Delta Dental PPO`"
50
$0
No
Unlimited
26
99
Yes
Unlimited
19
19
No
85% >:
50%
50%
50%
50%
Delta Dental Premier® '
525
$75
No
Unlimited
26
99
Yes
Unlimited
19
19
No
80%
50%
50%
50%
50%:: SO%'
Non Participating
550
$150
No
Unlimited
26
99
Yes
Unlimited
19
19
No
60%
40.E
40%
50%
This is a general description of coverage. It is not a statement of your contract. Actual coverage is subject to terms and conditions specified in the benefits document itself
and enrollment regulations in force when the benefits become effective. Certain exclusions and limitations apply. Please refer to your dental benefits document for details.
2014
Delta Dental of Iowa
9000 Northpark Dr, Johnston IA 50131 www.deltadentalia.com
Financial -Exhibit
Alternate 2
Changes on the Summary of Covered Services and Benefits exhibit are shown in red; all other benefits remain the same.
Employer Contribution
Single
Family
Plan Costs
Contracts
Self-insured incurred claim estimates
Complete this Section*
ER Contribution*
Number of benefit Eligible Employees*
Rates guaranteed from 01/01/2014 through 06/30/2014 (6 Months)
Single Family
155 514
$24.27 $77.15
Self-insured Administrative Fees - Weekly Settlement PEPM
Administrative Fee $3.55
Network Fee $0.25
Broker Fee $0.00
Total Administrative Fee $3.80
Recommended Rates (Includes Admin) $25.69
Annual Expense
$521,017
$81.67 $551,524
Please sign below and return to Delta Dental of Iowa at fax # 888-264-1433
*Please updateAmployer contribution and number of b nefit elliible employees above and sign below.
Signature'
Delta Dental of Iowa
Date
9000 Northpark Dr, Johnston IA 50131 www.deltadentalia.com