Dental – XKIG

Dental Plan

This year we are proud to offer two dental plan options for employees through the Anthem.

	PPO Base Plan	PPO Buy-Up Plan
Member Responsibility	In-Network	In-Network
Annual Deductible
Individual	$50	$50
Family	$150	$150
Deductible applies to:	Type 2 & 3	Type 2 & 3

Plan Coverage
Type 1 – Diagnostic & Preventative Oral exams, cleanings, x-rays, fluoride, sealants, space maintainers, emergency treatment	No charge	No charge
Type 2 – Basic Services Direct placement fillings, simple extractions, periodontal scaling & root planing	Ded., then 20%	Ded., then 20%
Type 3 – Major Services Dentures, bridges, crowns, inlays/onlays	Ded., then 50%	Ded., then 50%
Type 4 – Orthodontic Services (covers adults and children) Orthodontic Exams, X-rays, Extractions, Study Models and Appliances	Not covered	50%

Maximum Benefit (per covered person):
Types 1, 2 & 3 combined	$1,500 Per Calendar Year	$2,500 Per Calendar Year
Type 4, while covered by the plan	Not Covered	$2,500 Lifetime
Annual Maximum Type	MaxRewards® Included. A covered person may be eligible for the Rollover Amount for Types 1, 2 & 3 combined based on the following:
Eligible Range (claim threshold):	$1 - $800 Per Calendar Year	$0 - $900 Per Calendar Year
Rollover Amount:	$500 Per Calendar Year	$650 Per Calendar Year
Maximum Rollover Account Balance:	$1250 Rate assumes that all members’ Maximum Rollover Account Balance is $0 at time of takeover.	$1500 Rate assumes that all members’ Maximum Rollover Account Balance is $0 at time of takeover.

	WEEKLY RATES	WEEKLY RATES
Employee	$4.94	$6.34
Employee + Spouse	$9.68	$12.69
Employee + Child(ren)	$11.77	$15.54
Employee + Family	$17.84	$23.12