Onion Benefits Guide 2024 FINAL

DPPO DENTAL

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible

Individual: $50 Family: $150

Individual: $100 Family: $300

Benefit Maximum Annual (per person) Orthodontia Lifetime (per person)

$1,500 + Rollover $1,500

Diagnostic & Preventive Services Prophylaxis (Cleanings); Oral examinations; Topical fluoride; X-rays; Bitewing; Sealants (up to age 16); Space maintainers Basic Services Fillings; Extractions; Oral surgery; Endodontics; Periodontics; Periodontal surgery; Anesthesia; Consultations

0% (Employee Pays)

0% (Employee Pays)

10%* (Employee Pays)

20%* (Employee Pays)

Major Services Bridge and Dentures; Crowns, Inlays, Onlays

35%* (Employee Pays)

50%* (Employee Pays)

Orthodontic Services Adults and children

50% (Employee Pays)

50% (Employee Pays)

Semi-Monthly Contributions Employee Only Employee + Spouse/Domestic Partner Employee + Child(ren) Employee + Family

$25.76 $51.51 $58.17 $88.25

* after deductible

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