Optional Dental Plan Rates & Benefits
| |
Plan 1 |
Plan 2 |
Plan 3 |
| Benefit maximum |
None |
None |
None |
| Deductible (individual/family) |
$50/$150 |
$50/$150 |
$100/$300 |
| Benefits |
Member pays |
| Preventive and diagnostic services* |
No charge |
20% |
20% |
| Basic restorative services |
50% |
50% |
50% |
| Oral surgery, endodontics, and periodontics |
75% |
75% |
75% |
| Major restorative services |
75% |
75% |
75% |
| Orthodontics (for children and adults |
75% |
75% |
75% |
*Not subject to the deductible
|
| Monthly Premium |
0-24 |
25-44 |
45+ |
| Plan 1 |
| Subscriber only |
$39.53 |
$41.90 |
$44.27 |
| Subscriber + spouse/domestic partner |
$79.06 |
$83.80 |
$88.54 |
| Subscriber + child(ren) |
$79.06 |
$81.43 |
$83.80 |
| Subscriber, spouse, + child(ren) |
$118.59 |
$123.33 |
$128.07 |
| Plan 2 |
| Subscriber only |
$35.58 |
$37.71 |
$39.85 |
| Subscriber + spouse/domestic partner |
$71.16 |
$75.42 |
$79.70 |
| Subscriber + child(ren) |
$71.16 |
$73.29 |
$75.43 |
| Subscriber, spouse, + child(ren) |
$106.74 |
$111.00 |
$115.28 |
| Plan 3 |
| Subscriber only |
$32.76 |
$34.73 |
$36.69 |
| Subscriber + spouse/domestic partner |
$65.52 |
$69.46 |
$73.38 |
| Subscriber + child(ren) |
465.52 |
$67.49 |
$69.45 |
| Subscriber, spouse, + child(ren) |
$98.28 |
$102.22 |
$106.14 |
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