App. E, Part II |

DENTAL BENEFIT |

Employees and eligible family members will have the choice of PPO or Managed Care.

PPO Dental Plan
Member selects an in-network or an out-of-network provider.
Managed Care
Member selects a dentist in the provider network.

Plan Design:

Preventive
PPO In-Network
80% of PPO rate
PPO Out-of-Network*
80% of PPO rate
Managed Care
100%
Basic
PPO In-Network
80% of PPO rate
PPO Out-of-Network*
80% of PPO rate
Managed Care
85-75%
Major
PPO In-Network
50% of PPO rate
PPO Out-of-Network*
50% of PPO rate
Managed Care
70-65%
Individual Maximum Benefits Limit
PPO In-Network
$1,500 annually
PPO Out-of-Network*
$1,500 annually
Managed Care
None
*Deductible
PPO In-Network
None
PPO Out-of-Network*
$100 annually
Managed Care
None

Employee Contributions:

PPO
  • Employee: $0
  • Employee plus one: 100% contributory at rates determined by plan provider
  • Employee plus family: 100% contributory at rates determined by plan provider
Managed Care
  • Employee: $0
  • Employee plus one: $0
  • Employee plus family: $0

Table Of Contents » List of Appendices » HEALTH CARE AND RELATED BENEFITS » DENTAL BENEFIT