Download - 2013/14 Dental Benefits Option 2
• Coverage A: Preventative & DiagnosticDeductible: Zero in and out of networkCoinsurance: 20% in network 30% out of network
• Coverage B: Maintenance & Simple Restorative; Oral surgery; Periodontic & Endodontic Services
Deductible: Zero in network $50 out of networkCoinsurance: 20% In network 30% out of network
• Coverage C: Complex and Restorative DentistryDeductible: $25 in network $50 out of networkCoinsurance: 50% In network 50% out of network
2013/14 Dental Benefits Option 2
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2013/14 Dental Benefits Option 4Coverage A: Preventative & Diagnostic
Deductible: Zero in network and out of networkCoinsurance: 20% in network 30% out of network
Coverage B: Maintenance & Simple Restorative ; Oral Surgery; Periodontic & Endodontic Services
Deductible: Zero in network and out of networkCoinsurance: 20% in network 30% out of network
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2013/14 Dental Benefits Option 4Coverage C: Complex Restorative
Deductible: Zero in and out of networkCoinsurance: 20% in network 30% out of
network Coverage D: Orthodontic Dentistry
Deductible: Zero in network $25 out of networkCoinsurance: 50% in and out of networkContract benefit maximum: $2,000 Per covered
family member.
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Employee EE & Child(ren) EE & Spouse Family
$489.06 $904.78 $1,027.04 $1,379.05
Medical Rates
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Dental Rates Option 2Employee EE & Child(ren) EE & Spouse Family
$24.28 $44.90 $50.97 $68.47
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Employee EE & Child(ren) EE & Spouse Family
$45.71 $84.57 $96.00 $128.93
Dental Rates Option 4