X hits on this document

24 views

0 shares

0 downloads

0 comments

7 / 8

BENEFITs

KaIsER

INdEmNITy

Where to go for more information

1(800) 464-4000 http://www.kaiserpermanente.org

Trust Fund Office 1(888)547-2054 or 1(510) 633- 0333 www.carpenterfunds.com

dENTal BENEFITs - FoR KaIsER & INdEmNITy PaRTICIPaNTs

In-Network: Delta Dental PPO Dentist

Maximum - $2,500 per patient per calendar year Diagnostic & Preventive - 100% Contract Rate Basic Services - 80% Contract Rate Crowns & Cast Restorations - 80% Contract Rate Prosthodontics - 80% Contract Rate

Outside of Delta Dental PPO Network

Maximum - $2,000 per patient per calendar year Diagnostic & Preventive - 100% Contract Rate Basic Services - 50% Contract Rate Crowns & Cast Restorations - 50% Contract Rate Prosthodontics - 50% Contract Rate

Maximum

The maximum benefit is $2,500 per year, reduced to $2,000 for services of Non-PPO dentists. The above maximums are not separate maximums.

oRTHodoNTIC BENEFITs

Orthodontic Benefits for Dependent Chil- dren

Benefits covered by Indemnity Medical Plan, not Delta Dental. Plan pays 50% of cov- ered charges to a maximum of $1,500 per dependent child to the age of 19.

dEFINITIoNs

Generic

A drug identified by its chemical name - an equivalent version of a brand name drug whose exclusive patent has expired.

Multi-Source Brand

A brand name drug that has a generic equivalent.

Single Source Formulary Brand

A brand name drug that has no generic equivalent and is placed on a list of preferred formulary drugs by the pharmacy benefit manager.

Non-Formulary Drug

A drug that is NOT on a list of preferred formulary drugs.

Allowed Charge

The dollar amount the Fund has determined it will allow for covered Medically Neces- sary services or supplies performed by Non-Contract Providers.

Phantom COB (Coordination of Benefits)

If the participant’s spouse is employed and the employer offers insurance, the spouse must elect coverage.

Plan A & R Comparison

7

Document info
Document views24
Page views24
Page last viewedFri Dec 09 06:00:41 UTC 2016
Pages8
Paragraphs790
Words3109

Comments