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<br /> Indian River County BOCC-EMPLOYEES ONLY -TRIN r ACGROUP
<br /> INS U A All C E 9 N o K E A S114 & C o N 5 U L T A N T S
<br /> PPO Dental Insurance RFP Evaluation
<br /> Effective Date: October 1, 2014
<br /> Current Alternate#4
<br /> 'SCHEDULEa
<br /> OPP()Low,Plan DPPO High Plan
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<br /> OMNIVORE' ,.erwvrk tl N#Yl r u �0 11 N t1y ,r t�,,
<br /> Calendar YearMaximurri 51 f3C:1 ?l 500 $1,IrA ,;,500
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<br /> Single $50 $100 $25 1 $50 $50 1 $100 $25 fl $50
<br /> Family $150 1 $300 $75 1 $150 $150 i $300 $75
<br /> $150
<br /> Deductible Waived for Preventive 1 t I
<br /> Yes 1 Yes Yes 1 Yes Yes i Yes Yes ' Yes
<br /> Services?
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<br /> Preventative 100% 1 80% 100% 1 100% 100% 1 80% 100% 100%
<br /> Basic 80% 1 70% 100% i 80% 80% i 70% 100% 80%
<br /> Major 50% 40% 60% 1 50% 50% 1 4051 60% 50%
<br /> Orthodontia(Up to age 19) N/A N/A ) 50% 1 50% N/A 1 N/A 50% S0%
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<br /> Service Informanan y;
<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 Exfrirtrs 09/3D/2014 Expires 09/30/2014 24 Months 24 Months
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<br /> c.. ��//�. a� o r;', „;� v:'... y� .err ' i ,MOIL cost
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<br /> �_� PENN
<br /> � f r r tJ>ly ntAly
<br /> EE Only 58 94 $27.`x12 $38.58 $29.04 $1.12 $44.73 $6,15
<br /> EE+Spouse 18 37 $64.47 $90.58 $67.06 $2.59 $105.02 $14.44
<br /> Employee+Children 20 17 $58.60 $94.66 $60.95 $2.35 $109.75 $15.09
<br /> EE+Two or More 46 39 $95.16 $146.88 $98.98 $3.82 $170.29 $23.41
<br /> Monthly Premium $8,329.18 $14,315.52 $8,663.48 $16,597.42
<br /> Annual Premium $99,950.16 $171,786.24 $103,961.76 $199,169.04
<br /> $Increase N/A N/A $4,011.60 $27,382.80
<br /> %Increase N/A N/A 4.0% 15.9%
<br /> Annual Premium $271,736.40 $303,130.80
<br /> $Increase N/A $31,394.40
<br /> Increase N/A 11.6%
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