Dental Plan

Dental Benefits At-A-Glance

Monthly Premiums

 

We are pleased to offer high-level dental coverage through Delta Dental of Tennessee as part of the St. Jude benefits program.

If you choose dental coverage, you will need to select from one of two coverage tiers (Employee Only or Family). The medical plan coverage tiers do not apply. You can enroll for dental coverage whether or not you have medical coverage through St. Jude.

The St. Jude dental plan uses Delta Dental’s “Premier” and “PPO” networks. Within the network, the dental fees are negotiated, and you do not need to file a claim form. You will simply pay your coinsurance (20%) at the time of your visit. Preventive care is covered at 100%, subject to certain limitations. A listing of network dentists is available at www.deltadentaltn.com. You can search the “Delta Premier” network or the “Delta PPO” network. Providers in both networks are considered “in-network”; however providers in the Delta PPO network offer even deeper discounts.

If you choose to use a dentist who is not in the network, your percentage share of eligible expenses will remain the same; however, dental plan coverage will be based on reasonable and customary fees and not the dentist’s fees. You will pay your coinsurance (20%) plus the difference between the network rates and the dentist’s fees.

 

 

Dental Benefits At-A-Glance


Benefit
In-Network1
Out-of-Network2
Calendar Year Deductible
$0
Calendar Year Benefit Maximum (Orthodontics not included; combined for in-network and out-of-network services)
$1,500 per person per year
Lifetime Benefit Maximum for Orthodontics (combined for in-network and out-of-network services)
$2,000 per person per lifetime
Preventive and Diagnostic Dental Services
  • Periodic Oral Examinations (up to two visits per year, every six months unless qualified for additional cleanings)
  • Bitewing X-rays (one set in a 12-month period)
  • Complete Series or Panorex (full mouth) X-rays (once every three years)
  • Dental Prophylaxis (Cleanings)
  • Fluoride Treatments (up to age 19)
  • Space Maintainers (up to age 14)
Plan pays 100%
Plan pays 100% of R&C3

Dental Services

  • Fillings
  • Oral Surgery
  • Endontics
  • Periodontics
  • Sealants
  • Denture repairs
  • Emergency exams
  • Implants
  • Crowns
  • Bridges
  • Dentures
You pay 20%
Plan pays 80%
You pay 20%
Plan pays 80% of R&C3
Orthodontic Services
  • Benefits for procedures using appliances to treat poor alignment of teeth and/or jaws
You pay 20%
Plan pays 80%
You pay 20%
Plan pays 80% of R&C3

1The in-network percentage of benefits is based on the discounted fee negotiated with the provider.
2The out-of-network percentage of benefits is based on the reasonable and customary rates prevailing in the geographic area in which the expenses are incurred.
3R&C is reasonable and customary rates prevailing in the geographic area in which the expenses are incurred.

 

Back to top

 

Monthly Premiums

You and St. Jude Children’s Research Hospital share the costs of your dental coverage. Your premiums are deducted from 24 paychecks per year on a pre-tax basis. The table below shows your monthly contributions if you choose coverage under the plan.

2014 Benefits
Your Monthly Premium1
Monthly COBRA Rates2
Dental Full-time Part-time  
Employee only $9 $18 $33
Family $18 $36 $89

1Same Gender Domestic Partner—Family (incl. SGP) Tier (Full-time/Part-time/COBRA): $18 / $36 / $89
2This is the full cost of coverage if you or one of your dependents loses coverage under the plan and becomes eligible for COBRA.

 

Back to top