Page 6 - Murphy Research 2020-21 Employee Benefits

12/1/2020-11/30/2021 Employee Benefits Brochure

Dental EPO / PPO Plan – Principal

Your Copay/ Coinsurance In-Network Out-of-Network

Annual Benefit Maximum $1,500

Calendar Year Deductible:
$50 / $150 $50 / $150
Individual / Family

Preventive & Diagnostic:

100% covered 80% covered
Office Exams / Cleanings / X-Rays

Basic Services:

Fillings / Root Canal / Oral Surgery 80% covered 70% covered

Major Services:

Crowns / Dentures / Bridges 50% covered 50% covered

Orthodontia

Children only
50% coinsurance up to $1,000 lifetime maximum

*Please refer to carrier benefit summaries for more detailed information & out-of-network benefits. Non CA
members are subject to different benefits than listed above.
**For Out-of-Network services, member is responsible for any charges above allowable amounts. Out of network
annual max is $1,500.

PAGE 5