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Annual Max < $650	Annual Max $650-$1,000	Annual Max $1,000	Annual Max > $1,000
100% of first $100 50% of next $200 Annual Max $200	100% of first $200 75% of next $600 Annual Max $650	100% of first $200 80% of next $500 50% of next $800 Annual Max $1,000	100% of first $180 50% of next $2,040 Annual Max $1,200
100% of first $50 50% of next $300 Annual Max $200	80% of first $400 50% of next $750 Annual Max $700	100% of first $150 50% of next $1,700 Annual Max $1,000	100% of first $100 80% of next $500 50% of next $1,400 Annual Max $1,200
80% of first $500 Annual Max $400	100% of first $200 50% of next $1,000 Annual Max $700	80% of first $500 50% of next $1,200 Annual Max $1,000	100% of first $300 80% of next $750 50% of next $600 Annual Max $1,200
100% of first $200 50% of the next $600 Annual Max $500	0% of first $50 (deductible) 100% of next $100 80% of next $500 50% of next $500 Annual Max $750	100% of first $100 80% of next $250 50% of next $1,400 Annual Max $1,000	100% of first $150 75% of next $1,800 Annual Max $1,500
100% of first $150 80% of next $700 Annual Max $500	100% of first $100 80% of next $500 50% of next $500 Annual Max $750	100% of first $100 80% of next $500 50% of next $1,000 Annual Max $1,000	100% of first $180 50% of next $2,640 Annual Max $1,500
100% of first $500 Annual Max $500	100% of first $175 80% of next 250 50% of $750 Annual Max $750	100% of first $200 80% of next $1,000 Annual Max $1,000	100% of first $100 80% of next $500 50% of next $2,000 Annual Max $1,500
100% of first $200 50% of next $800 Annual Max $600	100% of first $100 75% of next $400 50% on next $800 Annual Max $800	100% of first $100 0% of next $50 (deductible) 80% of next $250 50% of next $1,400 Annual Max $1,000	100% of first $100 50% of next $2,800 Annual Max $1,500
100% of first $100 0% of next $50 70% of next $200 50% of next $720 Annual Max $600	80% of first $500 50% of next $1,000 Annual Max $900	100% of first $150 0% of next $50 (deductible) 80% of next $250 50% of next $1,300 Annual Max $1,000	100% of first $225 75% of next $1,700 Annual Max $1,500
100% of first $75 75% of next $300 50% of next $600 Annual Max $600		100% of first $200 50% of next $1,600 Annual Max $1,000	100% of first $500 50% of next $3,000 Annual Max $2,000
		100% of first $1,000 Annual Max $1,000	100% of first $500 75% of next $2,000 Annual Max $2,000
		100% of first $250 75% of next $1,000 Annual Max $1,000
		100% of first $150 0% of next $50 (deductible) 80% of next $500 50% of next $900 Annual Max $1,000
		80% of first $1,250 Annual Max $1,000
		80% of first $250 50% of next $1,600 Annual Max $1,000
		50% of first $2,000 Annual Max $1,000

 

 

Interpreting Plan Designs

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100% of first $200

80% of next $500

50%of next $2,800

Annual Maximum $ 2,000 

Explanation: Each Plan Year, a Participant will be reimbursed for 100% of the first $200.00 of any covered dental expenses incurred by the Participant or a covered dependent. If additional expenses are incurred the Employer will reimburse 80% of the next $500.00 of any covered dental expenses incurred by the Participant or a covered dependent. Thereafter, the Employer will reimburse 50% of any additional covered dental expenses incurred by the Participant or a covered dependent during the Plan Year up to the annual maximum.

Example: A Participant incurs a covered dental bill of $400.00. The Participant would be reimbursed $360.00, consisting of 100% for the first $200.00 of expenses and then the Plan would reimburse 80% of the next $200.00. Continuing the example, let’s say the Participant then incurs another $500.00 of covered expenses. The Participant would be reimbursed $340.00, consisting of 80% of $300.00, and then 50% of the next $200.00. All further expenses would be reimbursed at 50% until the total reimbursements for the year reached the maximum limit.

All limits are applied on the basis of the Plan Year. Unused benefits remain in the company’s DR Dental fund.

Copayment Levels for Covered Expenses:

Amount of Dental Expense	Employer Share	Employee Share	Paid Benefits
First $200	100%	0%	$200
Next $500	80%	20%	$400
Next $2,800	50%	50%	$1,400
Annual Maximum Benefits Paid			$2,000