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FOCUS ON BENEFITS 2021

Goodwill-Easter Seals Minnesota

DENTAL PLAN SUMMARY

This is a comprehensive plan for all dental services and covers preventive
care at 100% in-network, with no deductible. You may use any dentist for
your dental services; however, using an in-network provider will reduce
your out-of-pocket costs.

Features Low Plan High Plan
We offer the dental plan through The Standard.
Annual Maximum $1,000 $1,500
Always use an in-network provider to obtain
Annual Deductible $50/person; $50/person; the highest level of benefits.
Does not apply to preventive and $150/family $150/family
diagnostics
When accessing care out of network, there are
Diagnostic & Preventive You pay $0 You pay 0% no provider discounts and the member is

Basic Restorative Care You pay 20% You pay 20% responsible for the difference between what is
Amalgam & Resin Fillings charged/billed over the usual and customary
Oral Surgery You pay 20% You pay 20% percentile.
Simple Extractions
TO FIND A DENTIST
Endodontic Therapy You pay 20% You pay 20%
Root Canal
• Go to www.standard.com/dental
Periodontics You pay 50% You pay 50%
Gum disease • Type in your ZIP code and make sure to
select “Classic PPO”
Major Restoratives You pay 50% You pay 50%
Resins, Crowns
Prosthetics and Implants You pay 50% You pay 50%

Orthodontia No coverage 50% to $1,500
lifetime maximum*

*Eligible dependent children only.

Dental Plan Premiums: The rates are shown monthly and effective Jan. 1,
2021.

Per Payroll Rates
Status
Low Plan High Plan
Employee only $11.79 $15.05
Employee + 1 $24.69 $31.53
QUESTIONS?
Family $40.51 $51.74
Call customer service at 800-547-9515 or call
the phone number on the back of your ID card
or visit www.standard.com/dental

Please review your plan summary document for more detailed coverage
information.
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