PR - 4.2024 Employee Benefits Guide (FINAL)

DMO PLAN

PPO PLAN

BENEFIT

IN-NETWORK ONLY

IN-NETWORK**

OUT-OF-NETWORK***

Annual Deductible

Individual:

None None

Individual:

$50

Family:

Family:

$150

Office Visit Copay

See fee schedule

None

None

Annual Benefit Maximum

See fee schedule

$1,500

Diagnostic & Preventive Services Periodic Oral Examinations Radiographs Lab and Other Diagnostic Tests Prophylaxis (Cleanings) Topical Fluoride Sealants Space Maintainers

100% deductible waived

100% deductible waived

See fee schedule

Basic Services Restorations, Amalgams or Fillings Composite (Anterior & Posterior) Emergency Treatment/General Services General Services - Adjunctive Occlusal Guard General Services - Adjunctive Other Simple Extractions Oral Surgery (including surgical Extractions)

80% after deductible

60% after deductible

See fee schedule

Endodontics Periodontics Periodontal surgery

Major Services Emergency Treatment/General Services General Services - Adjunctive Anesthesia Inlays/Onlays/Crowns Dentures and Removable Prosthetics Fixed Partial Dentures (Bridges) Implants

50% after deductible

40% after deductible

See fee schedule

Orthodontic Services (children & adults)

50% up to $1,500 lifetime maximum

See fee schedule

Note: The DPPO Plan includes a roll-over maximum benefit. Some of the unused portion of your annual maximum may be available in future periods. **The DPPO network percentage of benefits is based on the discounted fees negotiated with the provider. ***The DPPO non-network percentage of benefits is based on the usual and customary fees in the geographic areas in which the expenses are incurred.

For addi Ɵ onal plan informa Ɵ on, please refer to your detailed plan design. In the event of a discrepancy, the carrier Plan Document shall prevail.

QUESTIONS? Call Bene fi tsVIP at 866.293.9736

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