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.
Now included: Preventive Incentive! Any Class I diagnostic or preventive service will not count toward the annual maximum.
The Level Plan also includes a pregnancy benefit that covers 1 additional cleaning, 1 additional periodontal maintenance, scaling and root planing, and 4 periodontal surgery procedures during pregnancy.
Weekly Dental Premium Rates
|Employee||EE + Child||EE + Spouse||Family|
|Waived for Preventive?||Yes||Yes|
|Dental Annual Maximum||$2,000||$2,000|
|Class I Diagnostic/Preventive Coinsurance|
|All Other X-rays||100%||100%|
|Cleaning & Fluoride Treatments||100%||100%|
|Class II Basic Coinsurance|
|Basic Restorative (Fillings)||100%||100%|
|Complex Oral Surgery||100%||100%|
|Crowns, Inlays, Onlays||80%||80%|
|Repairs to Crowns, Inlays, Onlays, Bridges & Dentures||80%||80%|
|Class III Major Coinsurance|
|Prosthetics (Bridges & Dentures)||10%||10%|