Level Dental Plan

The Level Plan offers lower premiums and a higher annual maximum.  The deductibles and coinsurance percentages are the same in and out-of-network.  If you use an out-of-network dentist, you may be required to pay the provider at the time of service, and you will incur higher out-of-network costs, including balanced billing charges over the maximum allowable charge (MAC).  The plan does not include orthodontia benefits.

Non-surgical periodontics, surgical periodontics, and prosthetics (bridges & dentures) are covered at 10% on the Level Plan.

Weekly Dental Premium Rates

Employee EE + Child EE + Spouse Family
$0.00 $3.63 $7.85 $14.55

Out-of-Pocket Costs

  In-Network Out-of-Network
Individual Deductible $10 $10
Family Deductible $25 $25
Out-of-Net. Reimbursement   MAC
Waived for Preventive? Yes Yes
Dental Annual Maximum $2,000 $2,000
Preventive Coinsurance 100% 100%
Basic Coinsurance 100% 100%
Major Coinsurance 80% 80%
Non-surgical Periodontics 10% 10%
Surgical Periodontics 10% 10%
Prosthetics (Bridges & Dentures) 10% 10%