Page 8 - Michigan Fitness Foundation 2021 Booklet
P. 8

Michigan Fitness Foundation

                                                    January 2021 Dental Renewal






                                                         Current                          Renewal
                                                   Blue Cross Blue Shield           Blue Cross Blue Shield
                                              PPO Plus 100/80/50/50 $1000 SG   PPO Plus 100/80/50/50 $1000 SG
             Plan Type                                    PPO                              PPO
             Plan Year                                    2020                             2021
                                                       In-Network                        In-Network
             Deductible
                  Family                                  $75                             $50/$75
                  Individual                              $25                               $25
             Class 1 - Preventive                          0%                               0%
             Class 2 - Basic                              20%                              20%
             Class 3 - Major                              50%                              50%
             Class 4 - Orthodontic                        50%                              50%
             Orthodontic Lifetime Maximum                $1000                             $1000
             Annual Maximum                              $1000                             $1000
             Waiting Period
             Provider Network                        Blue Dental PPO                   Blue Dental PPO
             Effective Date                             1/1/2020                         1/1/2021
             Total Number of Employees                     31                               31
             Monthly Total Dental Premium              $2,068.21                         $1,921.11
             Annual Total Dental Premium               $24,818.52                       $23,053.32
             Percentage Change From Current                                               -7.11%
             Annual Dollar Change From Current                                          ($1,765.20)
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