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%