Page 11 - Future Steps

Buy-Up Option 1

Advantage DPPO Non-Network
Network Network Provider
Class I Preventive 100% 100% 90%
Class II Basic 100% 100% 70%
Class III Major 70% 70% 50%
Calendar Year Deductible $25 $25 $50
Waived for Class I Yes Yes Yes
Calendar Year Maximum $1,500 $1,500 $1,000
Per Family Member
Class IV Orthodontia (child 50% 50% 50%
only)
Orthodontia Lifetime Max $1,500 $1,500 $1,500

Employee Contributions Biweekly
Employee Only $4.89
Employee + Spouse $10.52
Employee + Children $9.78
Family $15.17

Buy-Up Option 2

Advantage DPPO Non-Network
Network Network Provider
Class I Preventive 100% 100% 90%
Class II Basic 100% 100% 70%
Class III Major 70% 70% 50%
Calendar Year Deductible $25 $25 $50
Waived for Class I Yes Yes Yes
Calendar Year Maximum $2,000 $2,000 $2,000
Per Family Member
Class IV Orthodontia (child 50% 50% 50%
only)
Orthodontia Lifetime $1,500 $1,500 $1,500
Maximum

Employee Contributions Biweekly
Employee $7.89
Employee + Spouse $16.97
Employee + Children $15.78
Family $24.46

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