Onion Benefits Guide 2024 FINAL

IN-NETWORK ONLY (INO)

DHMO

BENEFIT

IN-NETWORK

IN-NETWORK ONLY

Annual Deductible

Individual: $100 Family: $300

None

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

$1,500 + Rollover $1,500

No Maximum

Diagnostic & Preventive Services Prophylaxis (Cleanings); Oral examinations; Topical fluoride; X-rays; Bitewing; Sealants (up to age 16); Space maintainers

0% (Employee Pays)

Basic Services Fillings; Simple extractions; Oral surgery; Anesthesia

30%* (Employee Pays)

Fee Schedule

Major Services Endodontics, Periodontics; Periodontal surgery; Surgical extractions; Bridge and Dentures; Crowns, Inlays, Onlays

50%* (Employee Pays)

Orthodontic Services Adults and children

50% (Employee Pays)

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

In-Network Only $5.05

DHMO $9.06 $18.12 $17.94 $29.87

$10.33 $14.30 $21.30

* after deductible

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