Benefit Guide - Circles

DENTAL BENEFITS

DMO PLAN

PPO PLAN

BENEFIT

IN-NETWORK ONLY

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible

Individual:

N/A N/A

Individual:

$50

Individual:

$75

Family:

Family:

$150

Family:

$225

Office Copay

$5

NA

N/A

Annual Maximum

None

$3,000

$3,000

Diagnostic/Preventive Services Include Periodic Oral Evaluation Cleaning, Fluoride Treatment & Sealants X-rays Space Maintainers

See Fee Schedule

100% of PPO negotiated contracted fee deductible waived Cleanings/Exams: Once every 6 months X-Rays: Bitewings two per calendar year

100% of R&C* charge deductible waived

Cleanings/Exams: Once every 6 months X-Rays: Bitewings two per calendar year

Cleanings/Exams: Once every 6 months X-Rays: Bitewings two per calendar year

Basic Services Include Fillings Simple Extractions & Oral Surgery (Includes surgical extractions) Periodontics & Endodontics

80% of PPO negotiated contracted fee after deductible

See Fee Schedule

80% of R&C* charge after deductible

Major Services Include Bridges Dentures Implants, Veneers Inlays, Onlays & Crowns

50% of PPO negotiated contracted fee after deductible

See Fee Schedule

50% of R&C* charge after deductible

Orthodontic Service

50% of PPO negotiated contracted fee after deductible Children (to age 19)

See Fee Schedule Adults & Children

50% of R&C* charge after deductible Children (to age 19)

Orthodontic Lifetime Maximum:

See Fee Schedule

$1,500

$1,500

Dependent Cut-off Age

26 Years Old

*Out-of-Network UCR is 90%. Certain services may be covered under the Medical Plan. Contact Member Services for more details.

BI -WEEKLY CONTRIBUTIONS

Bi -Weekly Contributions Employee Only

$6.35 $12.71 $15.09 $20.42

$33.84 $64.18 $83.39 $112.35

Employee + Spouse Employee + Children Employee + Family

Allows a portion of unused benefit maximum to carry over to next years benefit maximum amount. To qualify, you must have had a dental service performed and claim submitted within the plan year. You must not exceed the paid claims threshold.

Maximum Rollover

ANNUAL BENEFIT MAXIMUM

MAXIMUM ROLLOVER AMOUNT

IN-NETWORK ONLY MAXIMUM ROLLOVER AMOUNT

MAXIMUM ROLLOVER ACCOUNT LIMIT

THRESHOLD

$3,000

$1,000

$500

$750

$1,500

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

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