Benefit Guide - People

DENTAL BENEFITS

PPO PLAN BASE

PPO PLAN BUY-UP

BENEFIT

IN-NETWORK ONLY

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible

Individual: $50 Family: $150

Individual: $50 Family: $150

Individual: $50 Family: $150

Individual: $50 Family: $150

Annual Maximum

$1,500

$1,500

$2,000

$2,000

Diagnostic/Preventive Services Include Periodic Oral Evaluation Cleaning, Fluoride Treatment & Sealants X-rays Space Maintainers Basic Services Include Fillings Simple Extractions & Oral Surgery (Includes surgical extractions) Periodontics & Endodontics

100% of PPO negotiated contracted fee deductible waived

100% of R&C* charge deductible waived

100% of PPO negotiated contracted fee deductible waived

100% of R&C* charge deductible waived

Cleanings/Exams: Once every 6 months

Cleanings/Exams: Once every 6 months

Cleanings/Exams: Once every 6 months

Cleanings/Exams: Once every 6 months

80% of PPO negotiated contracted fee after deductible

80% of PPO negotiated contracted fee after deductible

80% of R&C* charge after deductible

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

50% of PPO negotiated contracted fee after deductible

50% of R&C* charge after deductible

50% of R&C* charge after deductible

Orthodontic Service

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

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

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

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

Orthodontic Lifetime Maximum:

$1,500

$1,500

$2,000

$2,000

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.

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

DENTAL PPO BASE PLAN

ANNUAL BENEFIT MAXIMUM

MAXIMUM ROLLOVER AMOUNT

IN-NETWORK ONLY MAXIMUM ROLLOVER AMOUNT

MAXIMUM ROLLOVER ACCOUNT LIMIT

THRESHOLD

$1,500

$700

$350

$500

$1,250

DENTAL PPO BUY-UP PLAN 2

ANNUAL BENEFIT MAXIMUM

MAXIMUM ROLLOVER AMOUNT

IN-NETWORK ONLY MAXIMUM ROLLOVER AMOUNT

MAXIMUM ROLLOVER ACCOUNT LIMIT

THRESHOLD

$2,000

$800

$400

$600

$1,500

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

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