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<br /> Indian River County BOCC-EMPLOYEES ONLY OCIE"M RING GROUP
<br /> PPO Dental Insurance RFP Evaluation I N 5 F A N fl B P O R ER 5� [o H 9U t T A N T s
<br /> Effective Date: October 1, 2014
<br /> Current Alternate 02
<br /> SCHEDULE Of
<br /> Florida Combined Life Mrida Combined Life sotstice�
<br /> OlueDental Choice Low Plan D; Choice High Plan y..,Low Plan I ,.,s High Plan 2
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<br /> Calendar Year Max, mkvm 51 0 0 $1,500 $1,0w
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<br /> . :,• r.:%,� �✓���s�.�� s2 � 9 r �� // ����.,� „r� / ���c„� ��'
<br /> Single $50 I $100 $25 i a $50 $50 $50 $25 i $25
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<br /> Family $150 t $300 $75 $150 $150 $150 $7S $75
<br /> Deductible Waived for Preventive Yes Yes Yes Yes Yes Yes Yes i Yes
<br /> Services?
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<br /> Benefits
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<br /> Preventative 100% a 80% 100% € 100% 100% a 80% 100% i 100%
<br /> Basic 80% « 70% 100% s 80% 80% 70% 1001% i 80%
<br /> Major 50% 40% 60% 50% 70% 40% 50% 50%
<br /> Orthodontia(Up to age 19) N/A § N/A 50% 50% N/A i N/A 50% 1 50%
<br /> i r
<br /> Service Infor'matian � � � y y ,y s
<br /> .mow ... __..
<br /> Out of Network Benefits Level Fee Schedule Fee Schedule Fee Schedule Fee Schedule
<br /> Waiting Period(Timely Entrants) None None None None
<br /> Orthodontia-Lifetime Max N/A $1,000 N/A $1,000
<br /> Endodontics/Periodontics Basic Basic Basic Basic
<br /> Rate Guarantee Expires 09/30/2014 Expires 09/30/2014 24 Months 24 Months
<br /> ..s' 7%f�
<br /> EE Only 58 94 $27.92 $38.58 € $28.99 $1.07 $40.22 $1.64
<br /> EE+Spouse 18 37 $64.47 $90.58 $66.95 $248 $94.44 $3.86
<br /> I I
<br /> Employee+Children 20 17 $58.60 $94.66 s $60.85 $2.25 $98.69 $4.03
<br /> E
<br /> EE+Two or More 46 39 $95.16 $146.88 $98.82 $3.66 $153,13
<br /> Monthly Premium $8,329.18 $14,315.52 $8,649.24 $14,924.76
<br /> Annual Premium $99,950.16 $171,786.24 $103,790.88 $179,097.12
<br /> $Increase N/A N/A $3,840.72 $7,310.88
<br /> %Increase N/A NJA 3.8% 4.3%
<br /> Annual Premium $271,736.40 d� $282,888.00 _~
<br /> $increase N/A $11,151.60
<br /> %Increase N/A 4.1%
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