15 / 28
Page 12
DENTAL INSURANCE
Dearborn National Dental
Benefit/Service
In-Network
Out-of-Network
Benefit
% of Maximum
Allowance
% of Reasonable
and Customary
Diagnostic, Preventive and
Miscellaneous Services
100%
100%
Basic
80%
80%
Major
50%
50%
Ortho
Not Available
Deductibles & Maximums
Deductible Individual *
$25
Calendar Year Maximum**
$1,500
* Does not apply to diagnostic, preventive and miscellaneous services.
** Per covered person.
In-Network
Dentist’s Usual Fee is:
$950.00
The In-Network Dental Provider Fee is:
$550.00
Your Plan Pays:
50% X $550 (In-Network Dental
Provider Fee):
-$275.00
Your Out-of-Pocket Cost:
$275.00
Out-of-Network
Dentist’s Usual Fee is
$950.00
Reasonable and Customary Fee:
$850.00
Your Plan Pays:
50% X $850 Reasonable and
Customary:
-$425.00
Your Out-of-Pocket Cost:
$525.00
By selecting an In-Network dentist in the above example, you save
$250
!
About Your Dental Insurance
An employee may receive benefits for two dental cleanings and exams at any time during the calendar year.
Dependent children are covered until the end of the year upon attaining age 26. Dependents with a disability are eligible
as long as they were incapacitated before the age limit was reached. There is no age limit for coverage on dependents
with a disability.
Network Savings Example
Your dentist says you need a crown, a Major service. The dentist’s usual fee is $950.00. The in-network dental provider
fee is $550.00 and the reasonable and customary fee for out-of-network is $850.00. (The example below assumes that
your annual deductible has been met.
Dental Plan (Actives)
Monthly
EE Cost
Employee Only
$0
Employee & Spouse
$31.46
Employee & Child(ren)
$31.46
Employee & Family
$62.86
Married/Dom Part w/full family
coverage
$15.62
Dental Plan (Pre 65 Retirees)
Monthly
Cost
Single
$31.63
Single & Spouse
$63.09
Single & Child(ren)
$63.09
Full Family
$94.49