DENTAL INSURANCE
Electronic Data, Inc. offers dental coverage through SunLife Financial. The Dental DPO 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 SunLife Financial’s amount and what the dentist may charge, also known as “balance billing”. The charts below provides a brief overview of the plans.
Dental DPO Plan F0122
In-Network
Out-of Network*
Calendar Year Deductible
$50
$50
Individual
$150
$150
Family
Annual Maximum
$1,500
$1,000
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
Covered 80%, after annual deuctible
Covered in full
Covered 80% after deductible
Covered 60% after deductible
Covered 50% after deductible
Covered 40% after deductible
Bridges Dentures
Orthodontia Services
Child Only (through age 18) 50% $1,500 Lifetime Maximum
• Subject to balance billing. Please refer to your plan document for specific details .
Employee Contribution 2018 – 2019 Coverage Year
Employer Paid Benefit Amount Monthly
Employer Paid Benefit Amount Annually
Employee Only
$0.00 $0.00 $0.00 $0.00
$28.40 $56.79 $57.32 $88.34
$ 340.80 $ 681.48 $ 687.84 $1,060.08
Employee + Spouse
Employee + Child(ren)
Family
5
Made with FlippingBook Annual report