Employee Only

$5.23

Employee Plus One

$10.46

Employee Plus Family

$17.26

Dental Benefits

Annual Maximum Benefits

$750

Deductible

$50

Coverage A - Exams, Intraoral Films and Bitewings

Waiting Period

0

Coinsurance

80%

Coverage B - Filings, Oral Surgery Repairs for Crowns, Bridges and Dentures

Waiting Period

3 months

Coinsurance

60%

Coverage C - Periodontics, Crown, Bridges, Endodontics and Dentures

Waiting Period

12 months

Coinsurance

50%

Employee Only

$4.20

Short-Term Disability Plan

Maximum Benefit Amount per Week

$150

Percentage of Weekly Base Pay

60%

Waiting Period (Benefits will begin paying immediately if hospitalized)

7 days

Employee Only

$0.60

Employee Plus One

$0.90

Employee Plus Family

$1.80

Term Life Plan

Employee Life Benefit (reduces to 75% at age 65, 50% at age 70)

$10,000

Spouse (terminates at age 70)

$5,000

Dependent (6 months to 24 years)

$5,000

Dependent (15 days to 6 months)

$1,000

Dependent (under 15 days)

$0

Vision Plan

Eye Examination for Eyeglasses

Frequency

Coinsurance

Deductible

Max Benefit

1 visit per 12 months

80%

$5 per visit

$25

Choice A: Eye Glasses

Lenses

2 lenses per 12 months

75%

$15 per purchase

$35-$75*

Frames

1 pair per 12 months

75%

$15 per purchase

$25

Choice B:

Contact Lenses

2 lenses per 12 months

75%

$15 per purchase

$95

Choice C:

Disposable Lenses

12 month supply per year

75%

$15 per purchase

$75

* Single Vision $35, Bifocal $35, Trifocal $50, Lenticular $75