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CU <br />C <br />0) <br />0 <br />(13 <br />(i) M <br />D S' <br />0 <br />(/) > <br />/Or+J (NJ <br />i <br />co <br />cn <br />C <br />0 Om <br />C <br />O <br />co 0 <br />L_ ...7. <br />2 ...7. <br />wM <br />I c., <br />0 a <br />C13 0) c, <br />2 <br />a) . _ <br />c tr 0 <br />r <br />(D 13., 0 <br />, <br />c <br />I2 ir— <br />CZ -0 <br />CO w ul <br />vl <br />wiEli r 7 <br />a) M <br />Tv <br />Co a3 <br />N <br />MARKET OPTION 7 <br />HealthPartners Inc <br />Dental Distinctions 2 Plan <br />INN INN OON <br />[BENEFIT LEVEL 1] [BENEFIT LEVEL 2] <br />O <br />10 <br />6q O <br />Z <br />O <br />t} <br />L <br />(a <br />0 <br />o o w u) <br />0 0 0>_ <br />,- ,- <br />N <br />o <br />c) <br />O- <br />0 0 0 o O 0 0 C <br />Lf. © O0 O Z~ 0 <br />Ef}Z <br />H <br />Maximum Allowable <br />Dental Distinctions 2 Plan <br />$33.45 $36.01 <br />$82.20 $76.67 <br />$134.35 $120.45 <br />$134.35 $120.45 <br />$49,315 $47,421 <br />Dollar Difference from Current 1 894 <br />0 <br />Percent Change from Current 3.84 / 0 <br />PLAN PROVISIONS <br />ON <br />000` I.$ <br />91$/5Z$ <br />L <br />O O L <br />ocpQ u) <br />O O O <br />E <br />O <br />co <br />O <br />.— O <br />N O O ( <br />O O O O O 0") z O <br />co co Li•) Z <br />$0 / $0 <br />$2,000 <br />No <br />OO <br />(B N_ <br />>> uj a) <br />0 o a_ to ' = o 0 0 0 o N 0 0 C <br />O O 0 O- 0 0 0 0 0 0 C 0 <br />O C. N} CO `~ CO co 10 10 10 co Z,— z <br />E co H <br />O) <br />N Ca <br />E <br />Q <br />CURRENT <br />Delta Dental of Minnesota <br />Dental Flex Plan <br />INN INN OON <br />[Delta Dental Premier] [Delta Dental Premier] <br />O0 <br />to O O <br />z <br />L <br />>N <br />o o N u) <br />0 0 0 <br />co co o>- <br />N <br />o <br />O <br />0 a) <br />0 0 0 > o O 0 0 c <br />O O O O O O z Lid 0 <br />Lo��Uin co E <br />Dentist Fee <br />Dental Flex Plan <br />O <br />Ln O <br />ER C' 0 <br />o.Z Lo to-oo00 <br />CE <br />>+ <br />0 o Qcn <br />0 <br />�> <br />+, <br />(Ni <br />o <br />10 <br />2� a) � <br />W O }� <br />0 0 0 > 0 0 0 c' c <br />O O <br />�1010U� co E <br />z <br />0 <br />C 0 <br />-z <br />o`— <br />in Ef} <br />tn- <br />L <br />>N <br />O O k 0 <br />00 cn� <br />- <br />N <br />O <br />0 a) -c <br />O O O > O 0 0 LO o <br />° Oz -E <br />���U� <br />O 12 Ef} N <br />z <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 />co co a) ti <br />IEstimated Annual Premium <br />Employee (EE) Only <br />EE + Spouse/EE + 1 <br />EE + Child(ren) <br />EE + Family <br />Total Enrollment <br />0 <br />y0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />CO <br />0 <br />N <br />L <br />U 0 <br />0 a' <br />E <br />0) <br />2 <br />o <br />co76 <br />W <br />O X <br />