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Dental Plans

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2015 Dental Plan Options
There are two dental plan options.  Both dental plans cover two cleanings and exams per member per Plan Year at 100% of the allowable charge at an in-network provider. Cleanings and exams do not count toward the Type A maximum. 

Basic Plan
Yearly maximums1 per Plan member:
Type A-$600 (No Deductible)
Type B & C and Implants—Not covered

Basic Plan

Benefits and Covered Services

PPO dentist

Premier dentist

Non-participating dentist

Type A Diagnostic & Preventive2 (D&P)—Does not count toward type A maximum

2 cleanings and exams per plan year at no cost

2 cleanings and exams per plan year at no cost

2 cleanings and exams per plan year at no cost + Balance billing

Type A Services2

0% + any costs incurred after annual maximum is met3

0% + any costs incurred after annual maximum is met3

0% + any costs incurred after annual maximum is met3 + Balance billing

Type B & C Services2—NOT COVERED (You pay full charged amount)

100%

100%

100%

Premium Plan 
Annual maximums1 per Plan member:
Type A-$600 (No Deductible)
Type B & C-$1,200 ($50 deductible per Plan member/$150 per family per calendar year)
Implants-$1,500 Lifetime Limit

Premium Plan

Benefits and Covered Services

PPO dentist

Premier dentist

Non-participating dentist

Type A Diagnostic & Preventive2 (D&P)—Does not count toward type A maximum

2 cleanings and exams per plan year at no cost

2 cleanings and exams per plan year at no cost

2 cleanings and exams per plan year at no cost + balance billing

Type A Services2

0% + any costs incurred after annual maximum is met3

0% + any costs incurred after annual maximum is met3

0% + any costs incurred after annual maximum is met3 + Balance billing

Type B Services2

20% + any costs incurred after annual maximum is met3

20% + any costs incurred after annual maximum is met3

20% up to annual maximum3 + balance billing

Type C Services2

50% + any costs incurred after annual maximum is met3

50% + any costs incurred after annual maximum is met3

50% + any costs incurred after annual maximum is met3 + balance billing

1After the plan pays the annual maximum, you are responsible for 100% of the cost of services. 

2 See the SPD for a full list of types A, B, and C services

3 See p. 15 for annual maximum amounts and limitations.  After the plan pays the annual maximum, you are responsible for 100% of the cost of services.