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 |
---|---|---|---|
$0.00 | $3.63 | $7.84 | $14.57 |
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 |
Class I Diagnostic/Preventive Coinsurance | ||
Exams | 100% | 100% |
Bitewing X-rays | 100% | 100% |
All Other X-rays | 100% | 100% |
Cleaning & Fluoride Treatments | 100% | 100% |
Sealants | 100% | 100% |
Space Maintainers | 100% | 100% |
Palliative Treatment | 100% | 100% |
Class II Basic Coinsurance | ||
Basic Restorative (Fillings) | 100% | 100% |
Simple Extractions | 100% | 100% |
Endodontics | 100% | 100% |
Complex Oral Surgery | 100% | 100% |
General Anesthesia | 100% | 100% |
Crowns, Inlays, Onlays | 80% | 80% |
Repairs to Crowns, Inlays, Onlays, Bridges & Dentures | 80% | 80% |
Class III Major Coinsurance | ||
Non-surgical Periodontics | 10% | 10% |
Surgical Periodontics | 10% | 10% |
Prosthetics (Bridges & Dentures) | 10% | 10% |