City Care Benefit
Dental Plan Summary
2006
Plan Year
Golden
West PPO Dental Plan RC1500 (High Option)
·
$50 Calendar Year Deductible
(waived for Preventive)
·
$1500 Calendar Year Maximum Benefit
per Member
·
Type I Preventive Services Covered
at 100%
·
Type II Basic Services Covered at
80%
·
Type III Major Services Covered at
50%
·
No Waiting Period for Major
Services for New Employees & Dependents
Monthly Premiums: Employee Only $45.05
Employee
& Spouse 91.10
Employee
& Child(ren) 88.69
Employee
& Family 134.73
Golden
West PPO Dental Plan RC1000 (Low Option)
·
$50 Calendar Year Deductible
(waived for Preventive/PPO Provider only)
·
$1000 Calendar Year Maximum Benefit
per Member
·
Type I Preventive Services
o
100% PPO Providers Only
o
80% Non-Participating Providers
·
Type II Basic Services Covered at
80%
·
Type III Major Services Covered at
50%
·
No Waiting Period for Major
Services
Monthly Premiums: Employee Only $34.77
Employee
& Spouse 70.14
Employee & Child(ren) 68.31
Employee
& Family 103.57
NOTE:
1.
PPO Dental Plan Rates are
Guaranteed to August 1, 2005.
2.
PPO Dental Plans will require 5 or
more enrolled employees in an employer group.
3.
PPO Dental Plans ARE available as a
dual-choice option with HMO Dental Plans (Still require 5 or more to enroll in
the PPO program).
Golden
West HMO Dental Plan 89L3 (High Option)
·
No Deductibles
·
No Charge for Diagnostic Exams and
Routine Cleanings Every Six Months
·
Additional Cleanings Covered with
Copayment
·
LOWER Member Copayments for All
Covered Services
o
Preventive
o
Prosthetics
o
Prosthodontics
o
Oral Surgery
o
Orthodontics
o
Adjunctive General Services
o
Material Upgrades
o
Cosmetic Dentistry (Elective
Services)
Monthly Premiums: Employee Only $14.58
Employee
& Spouse 26.39
Employee
& Child(ren) 28.27
Employee
& Family 40.89
Golden
West HMO Dental Plan PCP (Low Option)
·
No Deductibles
·
No Charge for Diagnostic Exams and
Routine Cleanings Every Six Months
·
Additional Cleanings Covered with
Copayment
·
HIGHER Member Copayments for All
Covered Services
o
Preventive
o
Prosthetics
o
Prosthodontics
o
Oral Surgery
o
Orthodontics
o
Adjunctive General Services
o
Material Upgrades
o
Cosmetic Dentistry (Elective
Services)
Monthly Premiums: Employee Only $11.01
Employee
& Spouse 17.68
Employee
& Child(ren) 16.74
Employee
& Family 25.64
NOTE:
1.
HMO Dental Plan Rates are
Guaranteed to August 1, 2006.
2.
HMO Dental Plans Will Cover 2+
Eligible Employee Groups.
3.
HMO Dental Plans ARE available as a
dual-choice option with PPO Dental Plans.
NOTE: City Care Benefits plan descriptions provide a brief summary of the benefits only and are not complete regarding all the provisions of the plans, including limitations and exclusions.
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