Dental Benefits

RIGHT START 4 KIDS (RS4K):
Kids 12 and under receive coverage at 100% for all services covered under the plan. Not subject to deductible. Subject to plan’s Annual Maximum, frequencies and limitations apply. Must see an in-network dentist or the plan’s underlying contract applies including waiting periods, deductibles and coinsurance levels.

Benefits	PPO	Premier	Non-Participating
Deductible (Individual/Family)	$25/$75	$25/$75	$25/$75
Annual Maximum Per Person	$1,500	$1,500	$1,500
Preventive & Diagnostic	Covered at 100%	Covered at 100%	Covered at 100%
Basic	80%	80%	80%
Major	50%	50%	50%
Orthodontics	50%	50%	50%

	Semi-Monthly Rate
Employee	$6.79
Employee + Spouse or Domestic Partner	$22.48
Employee + Child(ren)	$20.59
Family	$35.12

Downloads

Online Member Account

PREVENTIVE PLUS PROGRAM:
Diagnostic and preventive care services do not count towards your annual maximum. Services like exams, cleanings, x-rays, sealants and more do not count towards how much the plan will pay towards covered services. See flyer for more details.

Benefits	PPO	Premier	Non-Participating
Deductible (Individual/Family)	$25/$75	$25/$75	$25/$75
Annual Maximum Per Person	$2,000	$2,000	$2,000
Preventive & Diagnostic	Covered at 100%	Covered at 100%	Covered at 100%
Basic	90%	80%	80%
Major	60%	50%	50%
Orthodontics	50%	50%	50%