Dental Complete Classic 2ZGF Rates

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Baldric Robertson
5 years ago
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Dental Complete Classic 2ZGF Rates Rates are valid for 4/1/18 to 6/30/18 effective dates 100%/80%/50% $50 Diagnostic and $1,500 Maximum Allow ed 100%/80%/50% $150 Diagnostic and $1,500 90 Zip

01 N/A Zip Codes: 103-119 Low $61.02 $124.47 $156.08 $237.24 N/A $52.23 $106.56 $114.74 $174.40 N/A Zip Codes: 103-119 High $67.65 $138.01 $173.05 $263.04 N/A $57.91 $118.14 $127.21 $193.

1 Dental Complete Classic 2ZGF Rates Rates are valid for 4/1/18 to 6/30/18 effective dates 100%/80%/50% $50 Diagnostic and $1,500 Maximum Allow ed 100%/80%/50% $150 Diagnostic and $1, Zip Codes: Low $74.16 $ $ $ N/A $63.49 $ $ $ N/A Zip Codes: High $82.22 $ $ $ N/A $70.39 $ $ $ N/A Zip Codes: Low $61.02 $ $ $ N/A $52.23 $ $ $ N/A Zip Codes: High $67.65 $ $ $ N/A $57.91 $ $ $ N/A Diagnostic and Basic Services Major Services - Space maintainers o Groups with 2-4 eligible employees require 100% participation. All other occupations are Low Occupations 05770NYBENEBS_2ZGF Rev 09/2017

2 Dental Complete Classic 2ZGE Rates Rates are valid for 04/1/18 to 06/30/18 effective dates 80%/60%/50% $150 Diagnostic and $1,000 Maximum Allow ed Zip Codes: Low $40.70 $83.03 $ $ N/A $34.84 $71.08 $76.48 $ N/A Zip Codes: High $45.13 $92.06 $ $ N/A $38.63 $78.81 $84.79 $ N/A Zip Codes: Low $37.15 $75.78 $94.97 $ N/A $31.80 $64.88 $69.81 $ N/A Zip Codes: High $41.19 $84.02 $ $ N/A $35.26 $71.93 $77.41 $ N/A Diagnostic and Basic Services Major Services o Groups with 2-4 employees require 100% participation. All other occupations are Low Occupations 05770NYBENEBS_2ZGE Rev 09/2017

3 Dental Complete Classic 2ZGG Rates Rates are valid for 04/01/18 to 06/30/18 effective dates 100%/80%/50% $150 Diagnostic and $1, Zip Codes: Low $64.49 $ $ $ N/A $55.21 $ $ $ N/A Zip Codes: High $71.50 $ $ $ N/A $61.21 $ $ $ N/A Zip Codes: Low $53.06 $ $ $ N/A $45.42 $92.66 $99.77 $ N/A Zip Codes: High $58.83 $ $ $ N/A $50.36 $ $ $ N/A Diagnostic and Basic Services Major Services o Groups with 2-4 employees require 100% participation. All other occupations are Low Occupations 05770NYBENEBS_2ZGG Rev 09/2017

4 Dental Complete Voluntary 2ZGK Rates Rates are valid for 04/01/18 to 06/30/18 effective dates 100%/80%/50% $150 Diagnostic and $1, Zip Codes: Low $71.52 $ $ $ N/A $59.22 $ $ $ N/A Zip Codes: High $79.30 $ $ $ N/A $65.65 $ $ $ N/A Zip Codes: Low $58.85 $ $ $ N/A $48.72 $99.39 $ $ N/A Zip Codes: High $65.25 $ $ $ N/A $54.02 $ $ $ N/A Diagnostic and Basic Services Major Services Voluntary dental sold stand-alone or with medical: A minimum of two eligible employees must enroll in the stand-alone dental products. Twelve month waiting period for voluntary major services (waived if prior comparable coverage). All other occupations are Low Occupations 05770NYBENEBS_2ZGK Rev 09/2017

5 Dental Complete Voluntary 2ZGL Rates Rates are valid for 04/1/18 to 06/30/18 effective dates 100%/80%/50% $50 Diagnostic and $1,500 Maximum Allow ed 100%/80%/50% $150 Diagnostic and $1, Zip Codes: Low $82.25 $ $ $ N/A $68.10 $ $ $ N/A Zip Codes: High $91.19 $ $ $ N/A $75.50 $ $ $ N/A Zip Codes: Low $67.67 $ $ $ N/A $56.03 $ $ $ N/A Zip Codes: High $75.03 $ $ $ N/A $62.12 $ $ $ N/A Diagnostic and Basic Services Major Services Voluntary dental sold stand-alone or with medical: A minimum of two eligible employees must enroll in the stand-alone dental products. Twelve month waiting period for voluntary major services (waived if prior comparable coverage). All other occupations are Low Occupations 05770NYBENEBS_2ZGL Rev 09/2017

Dental Complete Classic 2ZGE Rates

Dental Complete Classic 2ZGE Rates 80%/60%/50% $150 Diagnostic and $1,000 Maximum Allowed Zip Codes: 100-101-102 Low $40.40 $82.42 $103.27 $156.98 N/A $34.59 $70.56 $75.92 $115.39 N/A Zip Codes: 100-101-102