2024 Employee Benefit Guide - Salaried - Yeled 11.3.23

PREFERRED PROVIDER ORGANIZATION DENTAL HIGH PLAN (PPO 30)

PREFERRED PROVIDER ORGANIZATION DENTAL LOW PLAN (PPO 20)

BENEFIT

IN-NETWORK

OUT-OF-NETWORK*

IN-NETWORK

OUT-OF-NETWORK**

Annual Deductible (Calendar Year)

Individual:

$50

Individual:

$50

Individual:

$50

Individual:

$50

Family:

$150

Family:

$150

Family:

$150

Family:

$150

Benefit Annual Maximum (Calendar Year) Orthodontia Lifetime Maximum

Individual: Individual:

$2,000 $1,000

Individual: Individual:

$2,000 $1,000

Individual:

$1,000

Individual:

$1,000

Not covered

Not covered

Preventive Services & Diagnostic Services Prophylaxis (Cleaning) Fluoride Treatment (Preventive) Sealants Space Maintainers Periodic Oral Evaluation Radiographs Lab and other Diagnostic Tests Basic Services Restorations (Amalgams or Composite) Emergency Treatment/General Services Simple Extractions Oral Surgery (incl. Surgical Extractions

Plan pays 100% No deductible

Plan pays 100% (U&C)* No deductible

Plan pays 100% No deductible

Plan pays 100% (MAC)** No deductible

Plan pays 80% After deductible

Plan pays 80% (U&C)* After deductible

Plan pays 100% After deductible

Plan pays 100% (MAC)** After deductible

Periodontics Endodontics

Major Services Inlays/Onlays/Crowns Dentures and Removeable Prosthetics Fixed Partial Dentures (Bridges)

Plan pays 50% After deductible

Plan pays 50% (U&C)* After deductible

Plan pays 60% After deductible

Plan pays 60% (MAC)** After deductible

Orthodontic Services Dependent Children to age 19 only

Plan pays 50% No deductible

Plan pays 50% (U&C)* No deductible

Not Covered

Not Covered

Dependent Age Limit: To age 26; benefits terminate at the end of the month in which the dependent turns 26

PRE-TAX SEMI-MONTHLY CONTRIBUTIONS

Employee

$41.66

$15.22

Employee & 1 (either a spouse or child)

$62.32

$10.78

Family

$93.31

$33.70

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.