Specifications include, but are not limited to: A. Required Plans. The following 3 PPO plan designs shall be used as a minimum basis for the Provider’s plan design. Any deviations from the following plan design shall be indicated in the approved Form 2, Dental Plan Proposal Worksheet. If deviations are not listed and approved services shall default to the following plan design. Benefits Low Plan Middle Plan High Plan Annual Maximum $1,000 per person per calendar year $1,000 per person per calendar year $1,500 per person per calendar year Carry Forward Annual Maximum Increase* (Adjusted Annual Maximum) $250 per person per each calendar year that Conditions met* $250 per person per each calendar year that Conditions met* $250 per person per each calendar year that Conditions met* Annual Deductible $50 per person to family max $150 for Basic or Major Services only $50 per person to family max $150 for Basic or Major Services only $50 per person to family max $150 for Basic or Major Services only Preventive Services 100% in network 100% in network 100% in network Basic Services 60% in network 70% in network 80% in network Major Services 30% in network 40% in network 50% in network Orthodontia Child Under 19 Adult None Paid at 40% in network up to lifetime limit of $1,000 None Paid at 50% in network up to lifetime limit of $1,000 Paid at 50% in network up to lifetime limit of $1,000 Out of Network Allowance 60th percentile of Usual & Customary 70th percentile of Usual & Customary Rate 80th percentile of Usual & Customary Rate *Carry Forward Annual Maximum Increase - requirements for each participating member (Adjusted Annual Maximum) 1. At least one Preventive Service (Periodic Oral Exam, Prophylaxis (cleaning), Bitewing x-rays) Carry Forward Annual Maximum Increase of $250 each year and accumulates annually, as long as condition 1 above is met to create the Adjusted Annual Maximum Reverts back to the Annual Maximum if condition 1 is not met. Members who receive at least one Preventive Service [Periodic Oral Exam, Prophylaxis (cleaning), Bitewing x-rays] during the plan year will benefit from a Carry Forward increase of $250 to the Plan’s Annual Maximum the next plan year. Year after year as members continue to receive preventive services, the Annual Maximum will increase the following year to a maximum increase of $750.
