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D <br />C <br />C <br />a <br />a) <br />i: <br />cy) <br />co <br />0 <br />(/) <br />a$ (13 <br />O <br />N <br />2 a) <br />O <br />po <br />I a) <br />CO CA W <br />Sm <br />N <br />O <br />a) > <br />a) C tui <br />I2 -a <br />co <br />CZ <br />4__ll • • <br />a) rt, <br />0 o N <br />MARKET OPTION 4 <br />Principal <br />Dental PPO <br />INN OON <br />[PPO Network] <br />000 ` 1.$ xew 01 %09 <br />009`L$ <br />051.$ / 09$ <br />L <br />Q) <br />CTS N O <br />r O <br />Oo \ U) O O O O > O 0 0 C <br />N 0 O) Lr <br />cooco �>- in in Lc) in O OOOVo �Z.-z <br />V O O ea <br />z ~ <br />0_ <br />N <br />90th ercentile <br />Dental PPO <br />= CO C1, <br />O M Cr) <br />oi O O <br />N ti = <br />to- co- <br />$42,689 <br />-$6,625 <br />-13.43% <br />O <br />O <br />O = <br />LO O <br />O X <br />L 0 <br />O 0 <br />o <br />O <br />Ln <br />m <br />C\v <br />CT, 2 ds O <br />o o !n o 0 0 \>\ N p 0 c <br />O O N O O O O O p 0 Oz L O <br />OO co' co LnLnLnULn =z <br />N Z <br />Q <br />N <br />CURRENT <br />Delta Dental of Minnesota <br />Dental Flex Plan <br />INN INN OON <br />[Delta Dental Premier] [Delta Dental Premier] <br />O <br />O <br />O O <br />z <br />L <br />(� <br />CU <br />>, O C3) <br />L O <br />o o O 2 o 0 0 0 > o p p 0 <br />OO 0. O OOOUO 0zLu <br />co Lf) <br />}' 0 N <br />(NJ <br />Dentist Fee <br />Dental Flex Plan <br />$33.45 <br />$82.20 <br />$134.35 <br />$134.35 <br />$49,315 <br />... <br />$50 / $150 <br />$1,500 <br />No <br />L <br />a) <br />02 <br />O O Q O O O O O p 0 O O O 0 <br />CO CO N >- in Ln LcLn 0 in ca Z 0 <br />}' O N <br />Z ~ <br />N <br />o <br />LO <br />r <br />69- O 0 <br />Z <br />O <br />in <br />L <br />a) <br />>, w rn <br />O O L <br />N \\ o > o N 0 0 p <br />00 00 Q>_ co O O LOn 0 O co Z <br />÷_, p & N <br />E ip z <br />N <br />Carrier Name <br />Plan Name <br />PLAN DESIGN* <br />Network <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 />OON Reimbursement Level <br />COST ANALYSIS <br />PEPM Rates - Enrollment per AMP Plan 1 <br />LL( COCO CA <br />Estimated Annual Premium <br />Dollar Difference from Current <br />Percent Change from Current <br />Employee (EE) Only <br />EE + Spouse/EE + 1 <br />EE + Child(ren) <br />EE + Family <br />O <br />N <br />0 <br />RS <br />0 <br />U <br />E <br />0 <br />O <br />0 <br />N <br />N <br />m <br />0 <br />Q. <br />0 <br />E <br />0 <br />0 <br />• <br />O <br />• <br />W <br />0 <br />Q <br />cu <br />z° <br />Principal has one additional routine or periodontal cleaning for expectant mother, diabetics and those with heart disease <br />Principal does not have waiting periods on their plan offering <br />