Page 9 - 2018 VER Benefit Guide

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 $1,500 $1,500 $1,500
Maximum*

Employee Contributions Biweekly
Employee Only $5.74
Employee + Spouse $12.34
Employee + Children $11.48
Family $17.80

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 $9.25
Employee + Spouse $19.91
Employee + Children $18.53
Family $28.70

* Children to age 19 are eligible for coverage

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