DENTAL INSURANCE
Gracepoint offers dental coverage through Aetna. The Dental PPO Plans allow you to use in-network or out-of-network benefits. If out- of-network dentists are used, you will be responsible for paying the difference between Aetna’s allowed amount and what the dentist may charge, also known as “balance billing”. The charts below provides a brief overview of the plans.
LOW Dental PPO Plan
HIGH Dental PPO Plan
In-Network
Out-of Network*
In-Network
Out-of Network*
Calendar Year Deductible Individual
$50
$100 $300
$50
$50
$150
$150
$150
Family
Annual Maximum
$1,250
$2,000
$1,250
Diagnostic & Preventive
Exams
Cleanings Fluoride X-Rays Sealants Regular Restorative Services Amalgam Fillings Extractions - Single Tooth Endodontics (Root Canal) Periodontics (Gum Disease) Major Services Crowns
Calendar Year Deductible
Covered in full
Covered in full
Covered in full
Covered 80% after deductible
Covered 50% after deductible
Covered in full after after deductible
Covered 80% after deductible
Covered 50% after deductible
Covered 25% after deductible
Covered 60% after deductible
Covered 50% after deductible
Bridges Dentures Orthodontia Services
50% $1,000 Lifetime Maximum
Not covered
Children only under the age of 19
• Subject to balance billing. Please refer to your plan document for specific details.
LOW PLAN Employee Cost Per Pay Period
HIGH PLAN Employee Cost Per Pay Period
Employee Only
$ 4.74 $10.45 $12.48 $20.85
$ 9.97 $31.54 $36.84 $54.58
Employee + Spouse Employee + Child(ren)
Family
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