|
|
|
|
|
Choice of Two Dental Plans |
|
Alpha/Omega |
|
Use Any Dentist |
|
Orthodontic Benefits Available |
|
Vision Benefits Included |
|
No Waiting Period for Preventative Dental Care |
|
Available as a Stand Alone Plan |
|
|
|
|
|
Calendar Year Max |
|
$1500 |
|
$500 (Class IV) |
|
Calendar Year Deductible |
|
$50 (X3) |
|
Preventative Waived |
|
Pretreatment Review |
|
$300 |
|
Covered Benefits |
|
Class I Preventative 100% |
|
Class II Basic 80% |
|
Class III Major 50% |
|
Class IV Orthodontia 50% |
|
Calendar Year Max |
|
$1000 |
|
Calendar Year Deductible |
|
$50 (X3) |
|
Preventative Waived |
|
Pretreatment Review |
|
$300 |
|
Covered Benefits |
|
Class I Preventative 100% |
|
Class II Basic 50% |
|
Class III Major 50% |
|
Class IV Orthodontia N/A |
|
|
|
|
|
|
Minimum Group Size |
|
10 |
|
Employer Contribution |
|
75% |
|
Participation Requirements |
|
Employee |
|
75% (5+) |
|
Dependent |
|
50% |
|
Usual, Customary and Reasonable |
|
Yes |
|
Minimum Group Size |
|
2 |
|
Employer Contribution |
|
75% |
|
Participation Requirements |
|
Employee |
|
100% (2-4)
75% (5+) |
|
Dependent |
|
50% |
|
Usual, Customary and Reasonable |
|
Yes |
|
|
|
|
|
|
|
MD Comprehensive Exam |
|
$75.00 |
|
OD Comprehensive Exam |
|
$60.00 |
|
MD Follow-up Exam |
|
$60.00 |
|
OD Follow-up Exam |
|
$60.00 |
|
|
|
MD Comprehensive Exam |
|
$37.50 |
|
OD Comprehensive Exam |
|
$30.00 |
|
MD Follow-up Exam |
|
$30.00 |
|
OD Follow-up Exam |
|
$30.00 |
|
|
|
|
|
|
|
Takeover Benefits |
|
Takeover means that employees are given credit
for waiting periods for like coverage's accumulated under an existing plan.
This only applies to groups with Five or more eligible insureds |
|
|
|
|
|
Premiums |
|
Initial 12 Months Rate Guarantee per Employee
Unit |
|
Only Three Areas |
|