Page 8 - Northbridge Companies 2018 OE Guide_Fomatting corrections (002)HLD
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Dental Coverage
ELECTIONS AND FORMS ARE DUE DEC. 8, 2017
Dental benefits are provided through Dental Blue. The Dental Blue plan allows you to seek treatment from the dentist of your
choice. However, using a dentist in the Dental Blue network will reduce your out of pocket costs.
The table below provides you with a brief overview of your costs under the dental plan. The table is not a contract and it does not
include all benefits, limitations, or exclusion provisions of the plan. If there is a discrepancy between this comparison and the plan
contracts, the plan contracts will govern.
Dental Blue Plan
Services In-Network Out-of-Network
Deductible (per calendar year)
Applies to basic and major services $0 for In-Network $50/ individual & $150/ family
Annual Maximum Benefit $1,500
(per calendar year)
Preventive Services
Exams, cleanings, x-rays, sealants for 0% 0%
children
Basic Services
Fillings, simple extractions, Endodontics,
Periodontal Maintenance 0% after deductible 20% after deductible
Major Services
Oral surgery, root canal, crowns, bridges, 40% after deductible 50% after deductible
dentures
Orthodontia Services (for dependent children up to age 19 only) - NEW BENEFIT
50% up to $1,000 lifetime maximum benefit 50% up to $1,000 lifetime maximum benefit
Appliances & related services
(combined in and out of network) (combined in and out of network)
Employee Contributions Per Pay Period
Dental Blue Plan
Employee Only $11.43
Employee + Spouse $26.17
Employee + Child(ren) $24.25
Family $34.09
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