Dental

Service Type 1

Service Type II

Service Type III

Preventative & Diagnostic Services

Basic Services 
 

Major Services
 

Routine Exams
Bitewing X-Rays
Routine Cleaning
Emergency Palliative Treatments
Sealants (for children)
Space Maintainers (for children)

Fillings
Crown & Bridge Repair
Denture Repair
Oral Surgery

Periodontics (treatment of gums)
Endodontics (root canal and pulpal therapy)
Crowns and Bridges
Dentures

Plan Benefit:

Plan Benefit:

Plan Benefit:

80% of Usual and Customary Charges

60% of Usual and Customary Charges

50% of Usual and Customary Charges
 

Waiting Period:

Waiting Period:

Waiting Period:

None

3 Months

12 Months

Weekly Rates:       Employee $4.45     Employee and Family $12.75

Term Life and Short-Term Disability (STD)

Term Life

Short-Term Disability (Employee Only):

• $10,000 employee Life benefit
• $10,000 matching Accidental Death benefit
• $2,500 Life only for eligible dependents ($500 through 6 months old)
• Benefits reduce 50% at age 70 for employee
• Spouse coverage ends at age 70

• Up to 26 weeks of coverage if disabled
• 50% of base pay to $125 per week
• 14-day waiting period for benefits
• Benefits reduce 50% at age 70

Weekly Package Rates: Employee $4.25/$.75*    Employee and Family $4.45/$.95*

*Where STD is not available because of statutory coverage.