DENTAL INSURANCE DENTAL PLAN INFORMATION
65%+ FTE FACULTY 75%+ FTE STAFF
ELIGIBILITY
PLAN INFORMATION
BASIC
COMPREHENSIVE
COMPREHENSIVE w/ ORTHO
$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
DOES NOT APPLY TO DIAGNOSTIC, PREVENTIVE, OR ORTHO SERVICES $2,000 PER PERSON, EXCLUDING ORTHODONTIC SERVICES
$1500 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 UP TO AGE 19
ORTHODONTIC SERVICES
NOT COVERED
NOT COVERED
EMPLOYEE CONTRIBUTION
NO COST NO COST NO COST NO COST
$12.29 $23.75 $24.25 $37.07
$15.95 $30.77 $41.76 $61.43
EMPLOYEE (EE) ONLY EE + CHILD(REN) EE + SPOUSE/DOMESTIC PARTNER FAMILY
DELTA DENTAL
PLAN ADMINISTRATOR
FOR MORE INFORMATION: www.deltadentaloh.com
EMPLOYEES HAVE 45 DAYS TO ENROLL VIA UC Flex/ESS IF NO ELECTIONS ARE MADE WITHIN 45 DAYS, EMPLOYEES WILL BE ENROLLED IN THE BASIC EMPLOYEE ONLY COVERAGE PLAN
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