Dental - 2022 | ARUP Laboratories

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$2,000 or $2,500 benefit coverage
Two preventive basic cleanings each year at no cost
Basic and major dental services coverage
Providers nationwide
Orthodontia benefits on the Dental Plus plan

Dental Select Benefits Summary

Platinum Network	Dental (2000) Summary Plan Description 2019 amendment		Dental Plus (2500) Summary Plan Description 2019 amendment
	Contracted Dentist	Non-Contracted Dentist	Contracted Dentist	Non-Contracted Dentist
Preventive
Routine exams, cleanings (2 per year), topical fluoride, x-rays, space maintainers, sealants	100%	100% of R&C	100%	100% of R&C
Basic
Composite fillings, extractions, oral surgery, endodontics, periodontics (No Waiting Period)	80%	80% of R&C	80%	80% of R&C
Major
Crowns, bridges, dentures, surgical implants (No Waiting Period)	50%	50% of R&C	50%	50% of R&C
Orthodontics
Lifetime Maximum All Members	No Benefit 20% Discount	No Benefit	$2000 20% Discount	$2000
Maximum Benefit (Applies to Basic and Major Services Per Benefit Period)
Benefit Period is Per Calendar Year	$2,000		$2,500
Deductible (Per Benefit Period)
Per Person: Family Maximum:	$50.00 $150.00	$50.00 $150.00	$50.00 $150.00	$50.00 $150.00
Specialists	Contracted Specialist payment:	Non-contracted Specialist payment:	Contracted Specialist payment:	Non-contracted Specialist payment:
Endodontists, Oral Surgeons, Pediatric, Periodontists, Prosthodontists	1) You receive a 20% discount off the Specialist fee 2) Plan pays according to the Reasonable and Customary fees 3) Member pays the difference between plan payment and discounted Specialist fee	Paid the same as non-contracted dentists	1) You receive a 20% discount off the Specialist fee 2) Plan pays according to the Reasonable and Customary fees 3) Member pays the difference between plan payment and discounted Specialist fee	Paid the same as non-contracted dentists

2022	Full Time		Part Time
	Monthly	Pay Period	Monthly	Pay Period
Dental (2000)
Single	$6	$3	$12	$6
Two party	$17	$8.50	$27	$13.50
Family	$23	$11.50	$36	$18
Dental Plus (2500)
Single	$23	$11.50	$33	$16.50
Two party	$54	$27	$86	$43
Family	$74	$37	$109	$54.50

2022	COBRA
Dental 2000 (Cost per month)
Employee	$31.62
Employee + 1 Child	$72.42
Employee + Spouse	$72.42
Employee + Children	$97.92
Employee + Family	$97.92
Dental Plus 2500 (Cost per month)
Employee	$43.86
Employee + 1 Child	$98.94
Employee + Spouse	$98.94
Employee + Children	$132.60
Employee + Family	$132.60

Dental Claim Form

Dental Select