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- 71w - Dental ]K 4 W,.j <br />Attachment number 1 <br />F -6 Page 79 <br />Renewal - 2014 - 2015 <br />Fully Insured <br />Renewal - 2015 - 2016 <br />Fully Insured <br />Renewal - 2015 - 2016 <br />Self- funded <br />PPO Option <br />Passive PPO Option <br />PPO Option <br />Passive PPO Option <br />PPO Option <br />Passive PPO Option <br />Preventive <br />Preventive <br />Preventive <br />Preventive <br />Preventive <br />Preventive <br />Cleanings <br />100% <br />100% <br />100% <br />100% <br />100% <br />100% <br />Exams <br />100% <br />100% <br />100% <br />100% <br />100% <br />100% <br />Fluoride Treatment <br />100% <br />100% <br />100% <br />100% <br />100% <br />100% <br />Bitewing X -Rays <br />100% <br />100% <br />100% <br />100% <br />100% <br />100% <br />Other X-Rays <br />100% <br />100% <br />100% <br />100% <br />100% <br />100% <br />S pace Maintainers <br />100% <br />100% <br />100% <br />100% <br />100% <br />100% <br />Basic <br />Basic <br />Basic <br />Basic <br />Basic <br />Basic <br />Sealants <br />80% <br />80% <br />80% <br />80% <br />80% <br />80% <br />A malgam Restorations <br />80% <br />80% <br />80% <br />80% <br />80% <br />80% <br />Denture Repair <br />80% <br />80% <br />80% <br />80% <br />80% <br />80% <br />Complex Extractions <br />80% <br />80% <br />80% <br />80% <br />80% <br />80% <br />S imple Extractions <br />80% <br />80% <br />80% <br />80% <br />80% <br />80% <br />A nesthesia <br />80% <br />80% <br />80% <br />80% <br />80% <br />80% <br />Major <br />Major <br />Major <br />Major <br />Major <br />Major <br />Periodontics <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />Endodontics <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />Crowns <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />Bridges <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />Dentures <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />Crown Repair <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />SO% <br />Orthodontics <br />Orthodontics <br />Orthodontics <br />Orthodontics <br />Orthodontics <br />Orthodontics <br />Adult & Child <br />Adult & Child <br />Adult & Child <br />Adult & Child <br />Adult & Child <br />Adult & Child <br />SO %to $1,250 <br />SO %to $1,250 <br />SO %to $1,250 <br />SO %to $1,250 <br />SO %to $1,250 <br />SO %to $1,250 <br />Deductible <br />$SO per individual <br />3 X Family Limit <br />$SO per individual <br />3 X Family Limit <br />$SO per individual <br />3 X Family Limit <br />$SO per individual <br />3 X Family Limit <br />$SO per individual <br />3 X Family Limit <br />$SO per individual <br />3 X Family Limit <br />Annual Maximum <br />$1,250 per person <br />$1,250 per person <br />$1,250 per person <br />$1,250 per person <br />$1,250 per person <br />$1,250 per person <br />Ameritas Rewards <br />Add <br />Add <br />Add <br />Add <br />Waiting Periods <br />None <br />None <br />None <br />None <br />None <br />None <br />PPO Deductible Reduction <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />Claim Reimbursement <br />In and Out of Network <br />In - Paid at <br />Contracted Rate <br />Out - Employee <br />Reimbursed at <br />Contracted Rate <br />In - Paid at Contracted <br />Rate <br />Out- Employee <br />Reimbursed at 90th UCR <br />In - Paid at <br />Contracted Rate <br />Out - Employee <br />Reimbursed at <br />Contracted Rate <br />In - Paid at Contracted <br />Rate <br />Out- Employee <br />Reimbursed at 90th UCR <br />In - Paid at <br />Contracted Rate <br />Out - Employee <br />Reimbursed at <br />Contracted Rate <br />In - Paid at Contracted <br />Rate <br />Out- Employee <br />Reimbursed at 90th UCR <br />Rate Guarantee <br />N/A <br />N/A <br />1 Year <br />1 Year <br />1 Year <br />1 Year <br />Premium Stabilization Reserve <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />Employee <br />$26.38 <br />$32.84 <br />$26.38 <br />$34.96 <br />$26.38 <br />$32.84 <br />Employee /Spouse <br />$54.10 <br />$67.32 <br />$54.10 <br />$71.68 <br />$54.10 <br />$67.32 <br />Employee /Child(ren) <br />$64.70 <br />$80.52 <br />$64.70 <br />$85.74 <br />$64.70 <br />$80.52 <br />Employee /Family <br />$92.42 <br />$115.00 <br />$92.42 <br />$122.48 <br />$92.42 <br />$115.00 <br />Rate Differential <br />100.0% <br />106.5% <br />100.0% <br />100.0% <br />Attachment number 1 <br />F -6 Page 79 <br />