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 in full
Covered 80%
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.
Dental Employee Cost Per Pay Period
Employee Only
$0.00 $0.00 $0.00 $0.00
Employee + Spouse
Employee + Child(ren)
Family
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