Group Number: 7777-0027

Eligibility Period: First of the month following date of hire.

Eligible Persons: Employees and dependents must be enrolled.  If applicable, enrolled employees must agree to payroll deductions for their coverage and their dependent(s).  If enrolling dependents, all eligible dependents must be enrolled for the term of the Agreement.  If dependent children are covered by the plan, unmarried dependent children will be covered from their second birthday until their 19th birthday; unmarried dependent children who are full-time students are covered until their 25th birthday.

Selected Benefits & Percentage Paid by Delta Dental

• Coverage A - Diagnostic & Preventive: 100%
• Coverage B - Basic: 80%
• Coverage C - Major: 50%
• Coverage D - Orthodontics: 50%

Maximum Contract Year Benefit: The maximum amount which your plan will pay is $1,000 per person per Contract Year.  Coverage D (Orthodontics) has a separate lifetime maximum of $750 for each eligible subscriber and dependent.

Deductible: There is a $50 deductible per person per Contract Year with a family deductible maximum of $150 per Contract Year.  This deductible is applied to Coverage B and C benefits.

Benefit percentages shown are based upon the actual charge submitted to a maximum of the participating dentist's approved fees, or Northeast Delta Dental's allowance for non-participating dentists.