Preferred Dental Plan
The Preferred Plan offers more comprehensive benefits, including orthodontia for dependent children to age 19, at a higher premium. 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 charges over the maximum allowable charge (MAC).
Now included: Preventive Incentive! Any Class I diagnostic or preventive service will not count toward the annual maximum.
The Preferred 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 |
|---|---|---|---|
| $3.95 | $9.58 | $16.48 | $28.05 |
Out-of-Pocket Costs
| In-Network | Out-of-Network | |
|---|---|---|
| Individual Deductible | $25 | $50 |
| Family Deductible | $75 | $150 |
| Out-of-Net. Reimbursement | MAC | |
| Waived for Preventive? | Yes | Yes |
| Dental Annual Maximum | $1,500 | $1,500 |
| Class I Diagnostic/Preventive Coinsurance | ||
| Exams | 100% | 75% |
| Bitewing X-rays | 100% | 75% |
| All other X-rays | 100% | 75% |
| Cleanings & Fluoride Treatments | 100% | 75% |
| Sealants | 100% | 75% |
| Space Maintainers | 100% | 75% |
| Palliative Treatment | 100% | 75% |
| Class II Basic Coinsurance | ||
| Basic Restorative (Fillings) | 100% | 75% |
| Simple Extractions | 100% | 75% |
| Endodontics | 100% | 75% |
| Nonsurgical Periodontics | 100% | 75% |
| Surgical Periodontics | 100% | 75% |
| Complex Oral Surgery | 100% | 75% |
| General Anesthesia | 100% | 75% |
| Class III Major Coinsurance | ||
| Inlays, Onlays, Crowns | 80% | 60% |
| Prosthetics (Bridges, Dentures) | 80% | 60% |
| Repairs of Crowns, Inlays, Onlays, Bridges & Dentures | 80% | 60% |
| Implants | 80% | 60% |
| Child Orthodontia | ||
| Diagnostic, Active, Retention, Treatment | 50% | 35% |
| Child Ortho. Lifetime Maximum | $1,000 | $1,000 |