Page 135 - 2018 Village Ordinance Book 122818
P. 135
Village of Sturtevant
Dental Proposal - May 1, 2018 Effective Date
Carrier Delta
Plan Name PPO Plus Premier
Enhanced Plan
Individual Deductible
Family Deductible Out-of-
Annual Maximum In-Network Network
Preventive Services
Ded Waived on Preventive $50 $75
Basic Services $150 $225
Major Services
Periodontics/Endodontics $2,000 $1,500
100% 100%
Orthodontia Yes Yes
90% 80%
60% 50%
90% 80%
70% to 50% to
$2,000 $1,500
Employee Only 6 $38.02
Employee & Spouse 7 $76.04
Employee & Child(ren) 0 $82.15
Family 6 $133.07
Monthly Premium $1,558.82 $0.00
Annual Premium $18,705.84
The above summary is only a brief description of benefits, for a more detailed com
