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• Coverage A: Preventative & Diagnostic Deductible: Zero in and out of network Coinsurance: 20% in network 30% out of network • Coverage B: Maintenance & Simple Restorative; Oral surgery; Periodontic & Endodontic Services Deductible: Zero in network $50 out of network Coinsurance: 20% In network 30% out of network • Coverage C: Complex and Restorative Dentistry Deductible: $25 in network $50 out of network Coinsurance: 50% In network 50% out of network 2013/14 Dental Benefits Option 2

Coverage A: Preventative & Diagnostic Deductible: Zero in and out of network Coinsurance: 20% in network 30% out of network Coverage B: Maintenance & Simple

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Page 1: Coverage A: Preventative & Diagnostic Deductible: Zero in and out of network Coinsurance: 20% in network 30% out of network Coverage B: Maintenance & Simple

• Coverage A: Preventative & DiagnosticDeductible: Zero in and out of networkCoinsurance: 20% in network 30% out of network

• Coverage B: Maintenance & Simple Restorative; Oral surgery; Periodontic & Endodontic Services

Deductible: Zero in network $50 out of networkCoinsurance: 20% In network 30% out of network

• Coverage C: Complex and Restorative DentistryDeductible: $25 in network $50 out of networkCoinsurance: 50% In network 50% out of network

2013/14 Dental Benefits Option 2

Page 2: Coverage A: Preventative & Diagnostic Deductible: Zero in and out of network Coinsurance: 20% in network 30% out of network Coverage B: Maintenance & Simple

2

2013/14 Dental Benefits Option 4Coverage A: Preventative & Diagnostic

Deductible: Zero in network and out of networkCoinsurance: 20% in network 30% out of network

Coverage B: Maintenance & Simple Restorative ; Oral Surgery; Periodontic & Endodontic Services

Deductible: Zero in network and out of networkCoinsurance: 20% in network 30% out of network

Page 3: Coverage A: Preventative & Diagnostic Deductible: Zero in and out of network Coinsurance: 20% in network 30% out of network Coverage B: Maintenance & Simple

3

2013/14 Dental Benefits Option 4Coverage C: Complex Restorative

Deductible: Zero in and out of networkCoinsurance: 20% in network 30% out of

network Coverage D: Orthodontic Dentistry

Deductible: Zero in network $25 out of networkCoinsurance: 50% in and out of networkContract benefit maximum: $2,000 Per covered

family member.

Page 4: Coverage A: Preventative & Diagnostic Deductible: Zero in and out of network Coinsurance: 20% in network 30% out of network Coverage B: Maintenance & Simple

4

Employee EE & Child(ren) EE & Spouse Family

$489.06 $904.78 $1,027.04 $1,379.05

Medical Rates

Page 5: Coverage A: Preventative & Diagnostic Deductible: Zero in and out of network Coinsurance: 20% in network 30% out of network Coverage B: Maintenance & Simple

5

Dental Rates Option 2Employee EE & Child(ren) EE & Spouse Family

$24.28 $44.90 $50.97 $68.47

Page 6: Coverage A: Preventative & Diagnostic Deductible: Zero in and out of network Coinsurance: 20% in network 30% out of network Coverage B: Maintenance & Simple

6

Employee EE & Child(ren) EE & Spouse Family

$45.71 $84.57 $96.00 $128.93

Dental Rates Option 4

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