UL - 2023-24 Benefits Guide (FINAL) SP

PPO (LOW) PLAN

PPO (HIGH) PLAN

BENEFIT

IN-NETWORK OUT-OF-NETWORK

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible (Calendar Year 1/1-12/31) (waived In-Network Preventive Services)

Individual: $50 Family: $150

Individual: $50 Family: $150

Individual: $0 Family: $0

Individual: $50 Family: $150

Annual Benefit Maximum

$1,500

$1,500

Diagnostic & Preventive Services Routine Exams; Routine Cleanings

100%

100%

100%

100%

(prophylaxis); Fluoride, Space Maintainers; Sealants; X-rays (bitewing & full mouth)

Basic Services Fillings and Stainless Steel Crowns; General Anesthesia; Simple Oral Surgery; Repairs to Partial Denture, Bridge, Crown, Relines, Rebasing, Tissue Conditioning; Adjustment to Bridge/Denture Major Services Complex Oral Surgical Procedures; Non-Surgical Periodontics, including Scaling and Root Planning; Periodontal Surgical Procedures; Simple Endodontics; Complex Endodontics; Crowns; Inlays; Onlays; Cast Post and Core; Bridges Replacement; Dentures Replacement

80%

50%

80%

80%

50%

40%

50%

50%

Orthodontic Services

Not Covered

Not Covered

Bi-Weekly Contributions (24-pay periods) Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

$5.00 $8.00 $8.00 $13.00

$13.00 $25.00 $26.00 $40.00

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