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SUNNYISLES <br />1703779 City of Sunny Isles Beach <br />BENEFITS AND COST SUMMARY FOR DENTAL PROPOSAL <br />• Option 1.03 <br />Proposed Effective Date: October 01, 2001 <br />PROPOSED SCHEDULE OF BENEFITS for Class 1 <br />Class 1: All Active Full -time Employees (Retired, temporary and seasonal employees are not eligible) <br />CALENDAR YEAR DEDUCTIBLE: <br />In Network <br />Deductible applies to: Type II and III <br />INDIVIDUAL $50 <br />FAMILY $150 <br />BENEFITS LEVELS <br />PPO Plan <br />TYPE I - Diagnostic & Preventive 100% <br />TYPE II - Basic Services 80% <br />TYPE III - Major Services 50% <br />TYPE IV - Orthodontia for Children 50% <br />Out of Network UCR - 90th percentile <br />MAXIMUM BENEFIT per covered person: <br />isTYPES I, II and III combined, per calendar year $1000 <br />TYPE IV, while covered by the plan $1000 <br />BENEFIT WAITING PERIOD Waived For: <br />TYPE II Expenses None <br />TYPE III Expenses 6 Months Current Participants <br />TYPE IV Expenses 12 Months Current Participants <br />Terms of the Prior Carrier Credit Provision may apply. <br />Out of Network <br />Type II and III <br />$50 <br />$150 <br />100% <br />80% <br />50% <br />50% <br />$1000 <br />$1000 <br />COST SUMMARY <br />Rates shown are monthly and are guaranteed for one year from the program effective date. <br />Eligible For PPO Plan <br />Employees with child ortho <br />Employee Only 62 $28.70 <br />Family 45 $71.10 <br />MONTHLY COST $4,979.28 <br />• <br />Jefferson Pilot Financial Insurance Company <br />2 11/05/01 <br />