Page 17 - Guide

Dental Benefits 2017 Beneits Enrollment

In-Network Out-of-Network
Annual Deductible $50 Single/$150 Family $50 Single/$150 Family
Waived for orthodontia and preventive
treatment
Maximum annual benefit $1,750 per person $1,500 per person
Preventive Services Plan pays 100% Plan pays 100% of
Includes exams and cleanings, fluoride covered charges
treatments, x-rays for diagnosis, sealants
Basic Services Plan pays 80% Plan pays 80% of
Includes fillings and extractions, covered charges after
periodontics, repairs to crowns or deductible
dentures, endodontics, oral surgery*
Major Care Services Plan pays 50% Plan pays 50% of
Includes crowns, inlays, dentures, dental covered charges after
implants deductible
Orthodontic services Plan pays 50% Plan pays 50% of
coverage for dependents to age 19 covered charges
Maximum lifetime orthodontia benefit $1,750 per person $1,500 per person

* Please note: oral surgery beneits apply to your calendar year maximum.

Dental Rates as of January 1, 2017

Dental Plan Monthly Employee Contribution
Employee (Ee) $10.55
Ee + spouse $22.15
Ee + child(ren) $18.98
Family $33.74
Preventive Dental
Care
When it comes to the health
of your teeth and gums,
preventive dental care is smart.
Brushing and flossing help
to remove plaque from the
surfaces and in between teeth,
keeping your teeth looking and
feeling clean. Routine dental
exams and regular cleanings
may help prevent the incidence
of higher-cost treatments such
as periodontal surgery, root
canals, extractions, and fillings.

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