Providence Engineering - 2023 Benefits Guide
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
DENTAL INSURANCE<br />
CARRIER: Sun Life<br />
●<br />
●<br />
●<br />
●<br />
You will pay less out of pocket when you choose an in-network provider.<br />
Locate an in-network provider at www.sunlife.com/us<br />
Be sure to ask for a pre-treatment estimate.<br />
Out-of-network providers can balance bill ( bill you for the difference between<br />
the provider’s charge and the allowed amount).<br />
DENTAL<br />
ELECTION<br />
SEMI-MONTHLY<br />
PAYROLL DEDUCTION<br />
Employee Only $0.00<br />
Employee & Spouse $29.88<br />
Employee & Child(ren) $37.50<br />
Employee & Family $67.67<br />
COVERED BENEFITS<br />
Deductible (per calendar year) Waived for Preventive<br />
Annual Plan Benefit Maximum<br />
Type I - Preventive Care Oral exams, cleanings, X-rays, fluoride treatment(1 in any<br />
6 month period)<br />
Bite-Wing x-Rays (1 in any 12 month period)<br />
Intraoral x-Rays (1 in any 60 month period)<br />
Type II - Basic Services Periodontal & endodontic services, oral surgery, fillings,<br />
simple extractions<br />
Periodontal Maintenance (1 in any 6 consecutive months)<br />
Type III - Major Services Inlays, onlays, crown restoration<br />
Bridges & dentures (10 year replacement limit)<br />
Dental Implants (10 year replacement limit)<br />
PLAN PAYS<br />
$50 per person, $150 per family<br />
$5,000 per covered member<br />
100%<br />
80%<br />
50%<br />
Orthodontia Services (Dependent Children to age 26) 50%<br />
Lifetime Orthodontia Plan Max (Dependent Children to age 26) $1,500<br />
15
Change language