GOLD PLAN
 
    - Level 1 - First $50.00 of expenses is applied to the deductible, 3 per family 
 
    - Level 2 - 50% of dental expenses up to a maximum benefit of $1,000 
 
*Service Waiting Periods: 3 months on Basic, 6 months on Major, 12 months for Orthodontics. 
Service waiting periods waived if the employer pays 100% of employee premiums 
Basic: Fillings and Sealants, Space Maintainers, Bleaching and Occlusal Guard 
Major: Crowns, Bridges, Dentures, Root Canals, Perio Surgery, and Oral Surgery 
Monthly Rates:
    - 
     4-Tier Employee $28.35 
 
    - Employee + 1 $46.80 
 
    - Employee + 2 $65.70 
 
    - Family $83.55 
 
*Service waiting period begins with your effective date of coverage.