DENTAL INSURANCE DENTAL PLAN INFORMATION
65%+ FTE FACULTY 75%+ FTE STAFF
ELIGIBILITY
COMPREHENSIVE w/ ORTHO
PLAN INFORMATION
BASIC
COMPREHENSIVE
$50 Per Person $150 Family
$50 Per Person $150 Family
$50 Per Person $150 Per Family
ANNUAL DEDUCTIBLE
Does Not Apply to Diagnostic or Preventive Services $1500 Per Person, Excluding Orthodontic Services
Does Not Apply to Diagnostic, Preventive, or Ortho Services $2,000 Per Person, Excluding Orthodontic Services
ANNUAL MAXIMUM BENEFIT
$500 Per Person
PREVENTIVE CARE
80% After Deductible
100% No Deductible
100% No Deductible
BASIC RESTORATIVE SERVICES
80% After Deductible
80% After Deductible
80% After Deductible
MAJOR SERVICES
60% After Deductible
80% After Deductible
80% After Deductible
60%* *Lifetime max $2,000 per eligible dependent age 18 and under
ORTHODONTIC SERVICES
Not Covered
Not Covered
EMPLOYEE CONTRIBUTION
EMPLOYEE (EE) ONLY EE + CHILD(REN) EE + SPOUSE/DOMESTIC PARTNER FAMILY
$19.95 $38.49 $52.23 $76.84
$15.37 $29.71 $30.34 $46.37
NO COST NO COST NO COST NO COST
PLAN ADMINISTRATOR
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