Page 8 - NH NC Guide

Dental Plan Summary

In-Network Out-of-Network
Plan Year Deductible/Maximum
Individual deductible $25 $25
Family deductible $75 $75
Calendar year maximum $1,000 $1,000
Coinsurance
Preventive services (Exams, x-rays, cleanings) 100% 100%
Basic (Fillings, root canals, oral surgery services) 80% 80%
Major services (Bridges, crowns, dentures) 50% 50%
Orthodontia
Coinsurance 50% 50%
Lifetime maximum $1,500 $1,500
Eligibility To age 19

Medical/Vision and Dental Rates—Pre-Tax Contributions

Medical/Vision Plan Cost
Coverage Tier HRA Participation Non-HRA Participation
Weekly
Employee $24.85 $62.31
Employee + spouse $79.71 $98.67
Employee + child(ren) $61.21 $117.17
Family $116.33 $153.79
Bi-Weekly
Employee $49.70 $124.62
Employee + spouse $159.41 $197.35
Employee + child(ren) $122.43 $234.33
Family $232.67 $307.59
Monthly
Employee $107.68 $270.01
Employee + spouse $345.39 $427.59
Employee + child(ren) $265.26 $507.72
Family $504.11 $666.44

Dental Plan Cost
Coverage Tier Weekly Bi-Weekly Monthly
Employee $5.77 $11.54 $25.00
Employee + spouse $11.02 $22.04 $47.75
Employee + child(ren) $9.23 $18.46 $40.00
Family $17.83 $35.65 $77.25

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New Hire Guide