DENTAL BENEFITS
The Suquamish Tribe Employee Plan ’ s dental benefits offer comprehensive coverage through Ameritas . You can access services from any licensed dentist you wish , however , your costs will typically be lower if you choose an Ameritas PPO dentist . Please see the information in “ Your Benefits Contacts ” toward the back of this Guide .
You have two dental plans to choose from , which are illustrated below .
If you wish to enroll in the ‘ Buy Up ’ plan , please note you will be required to stay enrolled on that plan for a 24-month period . This commitment does not apply to the ‘ Base ’ plan .
Always ask for a pre determination of benefits when your dentist suggests charges for a procedure in excess of $ 300 . This will outline what Ameritas will pay and what costs you will be responsible for .
USUAL , CUSTOMARY & REASONABLE
Benefits are paid at the negotiated fee level for in-network providers . Benefits for services from out-of-network providers will be paid at the 90th percentile of the amount charged by the majority of dentists in the area .
In-Network
Base Plan Out-of-Network
Annual Deductible ( waived for Preventive & Diagnostic ) |
$ 25 per person $ 75 per family |
Annual Benefit Maximum |
$ 2,500 per person |
Waiting Period |
12 Months for Major |
Services Preventive & Diagnostic |
No charge |
No charge |
Basic |
20 % after deductible |
20 % after deductible |
Major |
20 % after deductible |
20 % after deductible |
Periodontics |
Covered under Basic |
Endodontics |
Covered under Basic |
Implants |
Covered under Major |
Orthodontia |
Services |
Not Covered |
Buy-Up Plan |
( 2 Year Enrollment Required ) |
In-Network |
Out-of-Network |
Annual Deductible ( waived for Preventive & Diagnostic ) |
$ 25 per person $ 75 per family |
Annual Benefit Maximum |
$ 3,000 per person |
Waiting Period |
12 Months for Major |
Services Preventive & Diagnostic |
No charge |
No charge |
Basic |
20 % after deductible |
20 % after deductible |
Major |
20 % after deductible |
20 % after deductible |
Periodontics |
Covered under Basic |
Endodontics |
Covered under Basic |
Implants |
Covered under Major |
Orthodontia ( Adult & Child ) Services |
50 % |
50 % |
Lifetime Benefit Maximum |
$ 3,000 per person |
Limitations : This benefit outline is for illustrative purposes only . Actual claims paid are subject to maximum allowable charge , frequenci es , age limitations , terms and conditions of the contract .
Prepared by Gallagher for the Employees of The Suquamish Tribe 15