Page 17 - Deweys Benefits Enrollments Guide

Voluntary Dental Benefits
Group# 907-14-00149-000

Low Plan High Plan
Category
Amount You Pay Amount You Pay
100% UCR 100% UCR
Exams (2 per 12 months), Bitewing X-
Exams (2 per 12 months), rays (1 per 12 months), Space
Type I- Preventive Services Bitewing x-rays (1 per 12months), Maintainers, Emergency Palliative
Fluoride treatments (1 per 12 months Treatment, Sealants, Full Mouth x-rays,
for children under age 19) Fluoride Treatments (1 per 12 months
for children under age 19)
50% UCR 80% UCR
Type II - Basic Services Fillings, Anesthesia, Simple & Surgical Fillings, Anesthesia, Simple & Surgical
Extractions, Endodontics, Oral Surgery, Extractions, Endodontics, Oral Surgery,
Periodontics Periodontics

No Coverage 50% UCR
Type III – Major Services Crowns, Inlays, Onlays, Dentures,

Bridges, Implants
No Coverage 50% UCR
Type IV – Orthodontia
(for Adults & Children) Lifetime Orthodontia Maximum -
$1,000
Benefit Waiting Period No waiting period if enrolled timely No waiting period if enrolled timely

$50 Per Individual $50 Per Individual
Calendar Year Deductible Maximum of $150 per Family Maximum of $150 per Family
Waived for Type I Services Waived for Type I and Type IV Services

Calendar Year Maximum $1,000 $1,500
Employee only – $9.06 Employee only – $16.77
Employee Contributions
Employee & Spouse – $18.12 Employee & Spouse – $34.30
Per Pay Period Deduction
Employee & Child(ren) – $22.41 Employee & Child(ren) – $35.84
(26 pay periods)
Family – $32.01 Family – $57.06
UCR (Usual Customary Reasonable) is the allowable charge determined to be generally equal to or higher than 90%
of the actual charges submitted in the geographical region for the incurred procedure.

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