Level Dental Plan
The Level Plan offers lower premiums and a higher annual maximum. The deductibles and coinsurance percentages are the same in and out-of-network. If you use an out-of-network dentist, you may be required to pay the provider at the time of service, and you will incur higher out-of-network costs, including balanced billing charges over the maximum allowable charge (MAC). The plan does not include orthodontia benefits.
Now included: Preventive Incentive! Any Class I diagnostic or preventive service will not count toward the annual maximum.
The Level Plan also includes a pregnancy benefit that covers 1 additional cleaning, 1 additional periodontal maintenance, scaling and root planing, and 4 periodontal surgery procedures during pregnancy.
Weekly Dental Premium Rates
| Employee | EE + Child | EE + Spouse | Family |
|---|---|---|---|
| $0.00 | $3.63 | $7.84 | $14.57 |
Out-of-Pocket Costs
| In-Network | Out-of-Network | |
|---|---|---|
| Individual Deductible | $10 | $10 |
| Family Deductible | $25 | $25 |
| Out-of-Net. Reimbursement | MAC | |
| Waived for Preventive? | Yes | Yes |
| Dental Annual Maximum | $2,000 | $2,000 |
| Class I Diagnostic/Preventive Coinsurance | ||
| Exams | 100% | 100% |
| Bitewing X-rays | 100% | 100% |
| All Other X-rays | 100% | 100% |
| Cleaning & Fluoride Treatments | 100% | 100% |
| Sealants | 100% | 100% |
| Space Maintainers | 100% | 100% |
| Palliative Treatment | 100% | 100% |
| Class II Basic Coinsurance | ||
| Basic Restorative (Fillings) | 100% | 100% |
| Simple Extractions | 100% | 100% |
| Endodontics | 100% | 100% |
| Complex Oral Surgery | 100% | 100% |
| General Anesthesia | 100% | 100% |
| Crowns, Inlays, Onlays | 80% | 80% |
| Repairs to Crowns, Inlays, Onlays, Bridges & Dentures | 80% | 80% |
| Class III Major Coinsurance | ||
| Non-surgical Periodontics | 10% | 10% |
| Surgical Periodontics | 10% | 10% |
| Prosthetics (Bridges & Dentures) | 10% | 10% |