Page 9 - 2019 Hess Benefits Decision Guide
P. 9
Dental
You can get coverage for yourself
and your family by electing the dental plan, administered by Delta Dental. The plan pays for a wide range of services, including preventive, restorative and orthodontic, at more than 115,000 participating dentists.
Review the following chart to see what benefits the dental plan covers. You can go to any dentist you want, but note the difference in what you pay for services if you go out of network.
IN NETWORK
OUT OF NETWORK
Covered Services
DEDUCTIBLE
None
Individual: $50 Family: $150
PREVENTIVE CARE
100%
100%
RESTORATIVE CARE
80%
70% after deductible
PROSTHODONTIC CARE
60%
60% after deductible
ORTHODONTIC CARE (CHILDREN AND ADULTS)
50%
50% after deductible
ANNUAL MAXIMUM (PER PERSON)
$2,000
$1,500
ORTHODONTIC LIFETIME MAXIMUM (PER PERSON)
$2,500
$2,500
Coverage Level
Your Biweekly Contribution
EMPLOYEE ONLY
$6.96
EMPLOYEE + ONE
$13.92
EMPLOYEE + FAMILY
$20.88
EXPLORE THE NETWORK
To find an in network dentist, visit deltadentalins.com, click on Find a Dentist and select Delta Dental PPO or Delta Dental Premier or
call 1-800-932-0783.
DENTAL 7
