Dental Coverage

Quick Links:
» Resources
» Employee Monthly Rates
» Plan Year Maximum
» Plan Year Deductible
» Preventive & Diagnostic Services
» Basic Services
» Major Services
» Orthodonic Dental Services

Resources

» Provider Search: Click Here
» Video: Watch
» Coverage Highlight: Click Here
» Out of Network Claim Form: Click Here
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Employee Monthly Rates

Rate          Coverage Level
39.72    Employee Only
85.48    Employee & Spouse
61.12    Employee & Child
73.74    Employee & Children
89.64    Employee, Spouse & Child
107.00    Employee, Spouse & Children
» For Retiree, COBRA or Disability COBRA Rates, please contact the Health Plan's Administration Office
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Plan Year Maximum

$1,500
» Plan Paid - Does Not Include Amounts Paid by Member
» After Plan Paid Maximum is Reached, Member is Responsible for 100% of Incurred Charges
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Plan Year Deductible

$50
» Member Paid
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Preventive & Diagnostic Services

100% Plan Paid Twice Per Plan Year
» Not Subject to Deductible
» Examples Services Include: Cleaning, Polishing, Bite-Wing X-Ray’s and Prophylaxis
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Basic Services

80% Plan Paid
» 80% Plan Paid of Allowable In-Network Charges
» After Plan Year Deductible Is Met
» Up To Plan Year Maximum
» After Plan Year Maximum is Met, Member is Responsible for 100% of Incurred Charges
» Examples Services Include: Simple Extractions, Simple Fillings & Some Bridge Work
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Major Services

50% Plan Paid
» 50% Plan Paid of Allowable In-Network Charges
» After Plan Year Deductible Is Met
» Up To Plan Year Maximum
» After Plan Year Maximum is Met, Member is Responsible for 100% of Incurred Charges
» Examples Services Include: Complex Extractions, Complex Fillings, Major Bridge Work
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Orthodontic Dental Services

No Coverage
» This Dental Plan Does Not Include Coverage for Orthodontic Services
» See Optional Orthodontic Dental Coverage Details Here: Click Here
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