DENTAL Good oral care enhances overall physical health, appearance and mental well-being. Problems with the teeth and gums are common and easily treated health problems. Keep your teeth healthy and your smile bright with our dental benefit plan. PREMIUM 100/80/50/$50/$1,500/ORTHO/$1,000 ANNUAL DEDUCTIBLE Individual: $25 Family: $75 PREVENTIVE SERVICES Covered at 100% (services received are not applied to the plan year maximum benefit) BASIC SERVICES Plan pays 80% You pay 20% coinsurance after deductible MAJOR SERVICES Plan pays 50% 50% coinsurance after deductible ANNUAL PLAN MAXIMUM $1,500 ORTHO SERVICES Covered up to Lifetime Max Children up to age 19 ORTHO LIFETIME MAXIMUM $1,000 RATES PER BIWEEKLY PAY PERIOD Employee: $4.00 Employee + 1 Dependent: $7.00 Employee + Family: $10.00 The benefits and rates in this guide are for illustrative purposes only. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases. REVIEW PLAN SUMMARY