Mandatory Generic. Substitution If you choose a Non-preferred Brand drug (Tier 3) instead of its Generic equivalent, you will pay the highest copay plus, the difference in cost between the Non-preferred Brand drug and the Generic. If a Generic version is not available, you will only pay the copay. Delta Dental Eligibility Primary enrollee, spouse and eligible dependent children to the end of the month dependent turns age 26 Deductibles Deductibles waived for Diagnostic & Preventive (D & P) and Orthodontics? Delta Dental PPO dentists: $25 per person / $50 per family each plan year Non-Delta Dental PPO dentists: $50 per person / $150 per family each plan year Yes Maximums D & P counts toward maximum? $1,500 per person each plan year No Waiting Period(s) Basic Benefits None Major Benefits None Prosthodontics None Orthodontics None Diagnostic & Preventive Services Exams, cleanings, x-rays and sealants 100 % 65 % Surgical Removal of Impacted Teeth 100 % 65 % Basic Services Fillings, denture repair/relining, stainless steel crowns, bridges, bridge recementation/repair and posterior composite restorations 80 % 50 % Endodontics (root canals) Covered Under Basic Services 80 % 50 % Periodontics (gum treatment) Covered Under Basic Services 80 % 50 % Oral Surgery Covered Under Basic Services 80 % 50 % Major Services Crowns, inlays, onlays and cast restorations 50 % 30 % Prosthodontics Dentures 50 % 30 % Implants Covered only as an alternative to a fixed bridge 80 % 50 % Orthodontic Benefits Dependent children to age 19 50 % 50 % Orthodontic Maximums $800 Lifetime $800 Lifetime * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, PPO contracted fees for Premier dentists and PPO contracted fees for non-Delta Dental dentists. Delta Dental of Pennsylvania ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ ▇.▇. ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative. HLT_PPO_2COL_DDP (Rev. 4/17/2017) Delta Dental Eligibility Primary enrollee, spouse and eligible dependent children to the end of the month dependent turns age 26 Deductibles Deductibles waived for Diagnostic & Preventive (D & P)? $25 per person / $50 per family each plan year Yes Maximums D & P counts toward maximum? $1,500 per person each plan year No Waiting Period(s) Basic Benefits None Major Benefits None Prosthodontics None Diagnostic & Preventive Services Exams, cleanings, x-rays and sealants 100 % 100 % Basic Services Fillings, stainless steel crowns and posterior composite restorations 100 % 100 % Endodontics (root canals) 100 % 100 % Oral Surgery 100 % 100 % Periodontics (gum treatment) 0 % 0 % Major Services Crowns, inlays, onlays and cast restorations 0 % 0 % Prosthodontics Bridges and dentures 0 % 0 % * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and Premier contracted fees for non-Delta Dental dentists. Delta Dental of Pennsylvania ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ ▇.▇. ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative. HLT_PPO_2COL_DDP (Rev. 4/17/2017) This Memorandum of Understanding (MOU) constitutes an agreement between the Harford County Board of Education (Board) and the Harford County Education Association (HCEA). The Board and Association recognize that the current Collective Bargaining Agreements (CBA) for HCEA and HCEA (ESP) do not account for pharmacy service concerns with the implementation of the Mandatory M aintenance prescription program. Therefore both parties agree to discuss and address the unique and emergent issues.
Appears in 1 contract
Sources: Negotiated Agreement
Mandatory Generic. Substitution If you choose a Non-preferred Brand drug (Tier 3) instead of its Generic equivalent, you will pay the highest copay plus, the difference in cost between the Non-preferred Brand drug and the Generic. If a Generic version is not available, you will only pay the copay. Delta Dental Eligibility Primary enrollee, spouse and eligible dependent children to the end of the month dependent turns age 26 Deductibles Deductibles waived for Diagnostic & Preventive (D & P) and Orthodontics? Delta Dental PPO dentists: $25 per person / $50 per family each plan year Non-Delta Dental PPO dentists: $50 per person / $150 per family each plan year Yes Maximums D & P counts toward maximum? $1,500 per person each plan year No Waiting Period(s) Basic Benefits None Major Benefits None Prosthodontics None Orthodontics None Diagnostic & Preventive Services Exams, cleanings, x-rays and sealants 100 % 65 % Surgical Removal of Impacted Teeth 100 % 65 % Basic Services Fillings, denture repair/relining, stainless steel crowns, bridges, bridge recementation/repair and posterior composite restorations 80 % 50 % Endodontics (root canals) Covered Under Basic Services 80 % 50 % Periodontics (gum treatment) Covered Under Basic Services 80 % 50 % Oral Surgery Covered Under Basic Services 80 % 50 % Major Services Crowns, inlays, onlays and cast restorations 50 % 30 % Prosthodontics Dentures 50 % 30 % Implants Covered only as an alternative to a fixed bridge 80 % 50 % Orthodontic Benefits Dependent children to age 19 50 % 50 % Orthodontic Maximums $800 Lifetime $800 Lifetime * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, PPO contracted fees for Premier dentists and PPO contracted fees for non-Delta Dental dentists. Delta Dental of Pennsylvania ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ ▇.▇. ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative. HLT_PPO_2COL_DDP (Rev. 4/17/2017) Delta Dental Eligibility Primary enrollee, spouse and eligible dependent children to the end of the month dependent turns age 26 Deductibles Deductibles waived for Diagnostic & Preventive (D & P)? $25 per person / $50 per family each plan year Yes Maximums D & P counts toward maximum? $1,500 per person each plan year No Waiting Period(s) Basic Benefits None Major Benefits None Prosthodontics None Diagnostic & Preventive Services Exams, cleanings, x-rays and sealants 100 % 100 % Basic Services Fillings, stainless steel crowns and posterior composite restorations 100 % 100 % Endodontics (root canals) 100 % 100 % Oral Surgery 100 % 100 % Periodontics (gum treatment) 0 % 0 % Major Services Crowns, inlays, onlays and cast restorations 0 % 0 % Prosthodontics Bridges and dentures 0 % 0 % * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and Premier contracted fees for non-Delta Dental dentists. Delta Dental of Pennsylvania ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ ▇.▇. ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative. HLT_PPO_2COL_DDP (Rev. 4/17/2017) This Memorandum of Understanding (MOU) constitutes an agreement between the Harford County Board of Education (Board) and the Harford County Education Association (HCEA). The Board and Association recognize that the current Collective Bargaining Agreements (CBA) for HCEA and HCEA (ESP) do not account for pharmacy service concerns with the implementation of the Mandatory M aintenance prescription program. Therefore both parties agree to discuss and address the unique and emergent issues.
Appears in 1 contract
Sources: Negotiated Agreement