Dental Benefits
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible (Individual/Family) |
$50/$150 |
$50/$150 |
Annual Maximum Per Person |
$1,000 |
$1,000 |
Preventive |
100% |
95% |
Basic |
80% |
75% |
Major |
50% |
50% |
Orthodontia |
50% |
50% |
Orthodontia Lifetime Maximum Per Person |
$1,000 |
$1,000 |
Full-Time |
|
|---|---|
Employee |
$16.56 |
Employee + Spouse |
$32.34 |
Employee + Child(ren) |
$33.38 |
Employee + Family |
$54.85 |
Part-Time |
|
|---|---|
Employee |
$19.92 |
Employee + Spouse |
$40.11 |
Employee + Child(ren) |
$40.37 |
Employee + Family |
$66.76 |
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible (Individual/Family) |
None |
$50/$150 |
Annual Maximum Per Person |
$1,000 |
$1,000 |
Preventive |
See Schedule |
85% |
Basic |
See Schedule |
50% |
Major |
See Schedule |
30% |
Orthodontia |
The lesser of the amount charged or $1,000 |
50% |
Orthodontia Lifetime Maximum Per Person |
$1,000 |
$1,000 |
Full-Time |
|
|---|---|
Employee |
$6.99 |
Employee + Spouse |
$12.42 |
Employee + Child(ren) |
$11.38 |
Employee + Family |
$19.15 |
Part-Time |
|
|---|---|
Employee |
$10.35 |
Employee + Spouse |
$20.44 |
Employee + Child(ren) |
$18.63 |
Employee + Family |
$31.31 |