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cD <br />C <br />. (/) <br />CO a. <br />4-• <br />� M <br />I `A <br />O++ <br />coCV V <br />N <br />O <br />C 43) <br />a) • <br />11) <br />C <br />CD CO <br />CD N <br />A <br />c <br />PLAN DESIGN* <br />IN IN INN <br />Network [Delta Dental Premier] [Delta Dental Premier] OON Sun Life Dental Network OON <br />O <br />O <br />O—zo0 <br />L <br />a) <br />0-o <br />`a-^ <br />E L V J -cW <br />o <br />O ro <br />O O O O OO O O O <br />(a>��LiiLi>U z_ <br />O O N N <br />>' Z a) <br />L O <br />Q (0 <br />N O <br />H <br />$61.54 $66.54 <br />$100.58 $108.75 <br />$100.58 $108.75 <br />M <br />C7 <br />00 <br />to <br />PLAN PROVISIONS <br />Rate Guarantee 1 Year rate guarantee ending 12/31/2022 1 year rate guarantee <br />Eligibility FTE 30HRS/WK FTE 30HRS/WK <br />O <br />—O <br />L0 z <br />oEfl <br />b} <br />-c a) <br />0 <br />E N (n - <br />o O Cr\\\\ > O c <br />O O L O 0 0 0 0 O O O <br />ca>aO000U O Z <br />>N o„ <br />Z g <br />0_ Q <br />N 0 <br />H <br />r <br />0) <br />L <br />M <br />tce <br />ON <br />009` l.$ <br />09 l.$ / 09$ <br />L <br />CE <br />>+ a) rn <br />a) 000Q0 0 o O- >0L) 0aOOoa) z <br />00 co6�LLOLOLO0o0 N- E <br />69' <br />E O 1 N <br />z <br />N <br />OON Reimbursement Level Dentist Fee <br />COST ANALYSIS <br />PEPM Rates - Enrollment per AMP Plan 1 Dental Flex Plan <br />55 $33.45 <br />8 $82.20 <br />3 $134.35 <br />9 $134.35 <br />75 <br />r <br />v.)+� <br />40 <br />O <br />O <br />to-Lo z <br />\ <br />Loci <br />(a <br />>, a) O (1) <br />L a) O <br />o o Q 0) 0 0 0 0 0 o o) z O 0 <br />00 00 } in inLf) in U Lo <br />E o <br />z <br />N <br />O <br />O <br />Z <br />LO 69- <br />L <br />� , a) (3) -c <br />L <br />0 0 o_ 0 0 0 0 0 O p 0 0� O <br />O O u co LO LO LO U Lf) (0 Z <br />N— N— N +� 0 49" N <br />E z E <br />N <br />Calendar Year (CY) Deductible (Individual / Family) <br />Annual Maximum <br />Annual Maximum Provision <br />Coinsurance <br />Preventive Services <br />Periodontal Maintenance <br />Cleaning Frequency <br />Deductible Waived? <br />Basic <br />Periodontics <br />Endodontics <br />Major <br />Implants <br />Orthodontics <br />Maximum Age <br />Deductible <br />Lifetime Max <br />Ortho Waiting Period <br />'Estimated Annual Premium <br />Employee (EE) Only <br />EE + Spouse/EE + 1 <br />EE + Child(ren) <br />EE + Family <br />Total Enrollment <br />O <br />a) <br />0 <br />a) <br />i <br />0 <br />0) <br />0 <br />z <br />(0 <br />O <br />N <br />z E <br />O <br />O <br />E <br />• N <br />0) <br />CO -0 <br />c <br />OO L O <br />z <br />•0 <br />O <br />L <br />0 <br />a) <br />O <br />0 <br />a) <br />a) <br />O <br />C0 <br />C <br />a) <br />O <br />> <br />Q <br />0. <br />(0 <br />a) <br />L <br />''a^) <br />. vJ <br />N O <br />p) (0 <br />E a) <br />E <br />O > <br />U l— <br />a) L <br />l <br />O • � <br />0 <br />o 0 <br />M <br />c <br />(0 <br />uS <br />c a) <br />Loa_ <br />> <br />_ L <br />W/� <br />O U <br />(6 <br />•E a) <br />— Q <br />O > <br />C L <br />a) m <br />o - <br />L <br />W 0 <br />CD • O <br />(t, CV <br />O <br />c <br />O <br />Q <br />(0 <br />U Q <br />i U <br />co (Q <br />U m <br />O ▪ a) <br />O O w <br />- C O <br />Q • .c <br />O <br />• O L <br />O ^^O LL • (/) <br />E <br />N O� <br />O (� M <br />O> (a <br />i <br />0 '2 ) <br />C C <br />J m 73 <br />as <br />• A Late Entrant Benefit Waiting Period of 12 months for Type IV Orthodontic Services will apply to employees who enroll in this dental plan more than 31 days after becoming eligible. <br />