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Dental and Vision

Dental 2017-2018

Administered by Delta Dental

High and Low Dental Plans

Baptist Easley’s dental plans promote oral health by covering preventive services at 100 percent of usual and customary charges with no deductible. You can maximize your benefits when using Delta Dental’s PPO or Delta Dental’s Premier network of providers.

The following chart is only an overview. You should refer to your Summary Plan Description for any exclusions or limitations that may apply to the specific benefits.

HIGH LOW
Palmetto Health Dental Center In-Network* Delta PPO & Delta Premier Out of Network** Palmetto Health Dental Center In-Network* Delta PPO & Delta Premier Out of Network**
Deductible – Individual (waived at Palmetto Health Dental Center) $0 $15 $25 $0 $50 $75
PREVENTIVE SERVICES
– Oral examinations and routine cleaning of teeth limited to two per year
– Fluoride treatments, for dependents under age 18, limited to two per year
– Space maintainers for dependent children under age 18
– Emergency treatment to relieve pain
100% no deductible 100% no deductible 100% no deductible 100% no deductible 100% no deductible 100% no deductible
BASIC SERVICES
– Simple extractions (removal) of teeth
– Oral surgery (including impacted third molars)
– Hemi-section- Apicoectomy (cutting of the apex of a tooth root)
– Medically necessary services of an assistant surgeon- Surgical periodontic examination
90%, after deductible 80%, after deductible 80%, after deductible 70%, after deductible 50%, after deductible 50%, after deductible
MAJOR SERVICES
– Fixed bridgework, partial or full dentures
– Inlays, onlays and crowns
80%, after deductible 60%, after deductible 60%, after deductible 65%, after deductible 50%, after deductible 50%, after deductible
Orthodontic Deductible – Per Individual n/a $0 $50 n/a n/a n/a
ORTHODONTIC SERVICES not covered 50% $2,500 lifetime max 50%, $2,000 lifetime max not covered not covered not covered
Plan
Dental PPO
Tier
High DPPO (Easley)
Low DPPO (Easley)
Bi-Weekly Contributions
EE Only
$12.24
$7.14
EE + Spouse
$21.42
$12.24
EE + Child(ren)
$24.48
$13.26
EE + Family
$39.78
$20.40

* No balance billing when using the Delta Dental PPO network or the Delta Dental Premier network.
** Coinsurance is based on a percent of usual and customary fees
Delta Dental provider directory:
www.DeltaDentalSC.com (choose PPO or Premier network)

Vision 2017-2018

Administered by BlueCross BlueShield of South Carolina

Our Baptist Easley vision plan, which is administered by BlueCross BlueShield of South Carolina, provides reimbursement for a vision exam, lenses for frames, frames, and contact lenses purchased by a licensed provider of your choice.

BENEFIT

ANNUAL ALLOWANCE

Annual Allowance @ Palmetto Health Ophthalmology

Vision Exam $45 100% Reimbursed*
Corrective Lenses $90 $120
Frames $60 $80
Contact Lenses $150 $175

*One visit per calendar year.

Your Bi-weekly Vision Premiums

Tier

Bi-weekly contributions

Team member  $4
Team member + Spouse $7
Team member + Child(ren) $7
Family $11

 

Palmetto Health Ophthalmology Associates

9 Richland Medical Park Drive, Suite 340
Columbia, SC 29203
Phone: 803-434-2020
Fax: 803-434-1581

100 Palmetto Health Pkwy., Suite 350
Columbia, SC 29212
Phone: 803-907-2020
Fax: 803-907-2019
Office Hours: Monday – Friday, 8 a.m. – 5 p.m.

Appointments

Please arrive 15 minutes prior to your appointment time to complete paperwork. You will need your insurance card, picture identification (such as a driver’s license) and any medications you are currently taking. Please provide 24 hours’ notice if cancelling an appointment.

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QUESTIONS?

Contact the Total Rewards

Benefits Service Center at (800) 963-3456

or email TotalRewards@PalmettoHealth.org

Plan Year: January 1 through December 31, 2018

Copyright © 2017-2018 Baptist Easley