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|
2010 Dental Benefits
| Dental Premiums |
|
Per Pay Period |
Per Month |
| Employee |
$8.50 |
$17.00 |
| Employee/Spouse |
$17.00 |
$34.00 |
| Employee/Child(ren) |
$22.75 |
$45.50 |
| Family |
$31.25 |
$62.50 |
|
|
Benefit Limits |
| Deductible – (per person per calendar year) |
$50 |
|
Does not include Type I services |
|
Calendar Year Maximum - for Types I, II and III combined
per covered person
|
$1,000 |
Lifetime Maximum – for Type IV – Orthodontics per covered
person
|
$1,500 |
| Covered Charger |
Per Covered Person |
|
Type I – Preventive Procedures
- routine examinations
- cleaning
- x-ray
examinations
|
100% |
|
Type II – Basic Procedures
- regular cavity fillings
- non-surgical tooth extractions
- repair
of crowns and bridges
- removal of wisdom teeth
|
80% |
|
Type III – Major Procedures
- abutment crowns
- initial full or partial dentures
|
50% |
|
Type IV – Orthodontics Procedures |
50% |
Examples are limited and do not include all applicable services.
There are no network limitations on which dentist you choose.
Questions? Contact Cathy Moore at 458-7168 or cmoore@pcrmc.com
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