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1999-081
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1999-081
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Last modified
7/27/2023 12:21:25 PM
Creation date
7/27/2023 12:21:21 PM
Metadata
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Template:
Official Documents
Official Document Type
Miscellaneous
Approved Date
03/23/1999
Control Number
1999-081
Subject
Dental Insurance Modification/Guardian
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of <br />40 <br />J <br />GUARDIAN <br />PLAN A <br />$1,500 Annual Maximum Benefit <br />$1,000 Maximum Orthodontia Benefit (Lifetime) <br />In Network Out of Network <br />$25 Deductible $75 Deductible <br />100% <br />Preventative/Diagnostic <br />100% <br />100% <br />Basic Care <br />80% <br />60% <br />Major Care <br />50% <br />50% <br />Orthodontic <br />50% <br />Monthly Premiums: <br />Family Rate $62.01 <br />Employee <br />$25.15 <br />waive the deductible for preventative services in network, but do not waive <br />Spouse <br />$33.91 (additional) <br />Child(ren) <br />$28.49 (additional) or <br />Family Rate $87.56 <br />Orthodontia <br />$ 8.08 (additional) <br />Orthodontia $ 8.08 <br />PLAN B <br />$1,000 Annual Maximum Benefit <br />No Orthodontia Benefit <br />In Network <br />Out of Network <br />$50 Deductible <br />$100 Deductible <br />100% Preventative/Diagnostic <br />80% <br />80% Basic Care <br />70% <br />50% Major Care <br />40% <br />Monthly Premiums: <br />Employee $18. i 9 <br />$23.82 (additional) or <br />Family Rate $62.01 <br />Spouse <br />Child(ren) $20.00 (additional) <br />waive the deductible for preventative services in network, but do not waive <br />Both plans <br />the deductible for preventative services out of network. <br />
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