 |
Benefit Description |
In Network |
Out of Network |
 |
| |
Deductible (waived for preventive) |
$50/$150 |
$50/$150 |
|
| |
Calendar Year Maximum |
$2,000 |
$2,000 |
|
| |
Orthodontic Lifetime Maximum |
$1,500 |
$1,500 |
|
| |
Waiting Periods |
None |
None |
|
| |
Reimbursement structure In/ Out |
PPO |
MAC |
|
| |
Preventive Services |
100% |
100% |
|
| |
Oral Exams, X-rays, emergency office visits, Cleaning, Topical application of Fluoride Solutions, and Sealants (limited to children under age 16)
|
100% |
100% |
|
| |
Basic Services |
80% |
80% |
|
| |
Denture Repairs, Fillings and Space |
80% |
80% |
|
| |
Maintainers |
80% |
80% |
|
| |
Restorations |
50% |
50% |
|
| |
Major Services |
50% |
50% |
|
| |
Oral Surgery |
50% |
50% |
|
| |
Endodontics |
50% |
50% |
|
| |
Periodontics |
50% |
50% |
|
| |
Crowns, Prosthodontics, Dentures |
50% |
50% |
|
MAX MULTIPLIER ™
Preventive waived for out-of-network
Increased calendar year maximums to $2,000
Prenatal benefits
Increase maximum benefits up to $3,500 using the Max Multiplier™ program
Lower premiums
Employee & Dependent Coverage available
|
*Only affects 20 Bi-weekly members: These are the standard rates for 2008 and 2009. Due to the shortened 8 Bi-weekly payment cycle the premiums will be slightly higher for 2008 because your benefits will start July 1, 2008.
|
|
