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Pathfinder Pequot Lakes <br /> Presented By:IEB a DELTA DENTAL° <br /> DENTAf- MN,56472 <br /> Dental Plan Design&Rates <br /> Enrollment: Quoted Participation Requirements: <br /> 5+Employees This proposal requires a minimum of 20%participation of eligible employees and dependents,that are not <br /> enrolled covered by another dental plan. <br /> Deductible: $100 Lifetime Deductible per person.Applies to all covered services,including Diagnostic and Preventive. <br /> Each covered member is responsible for first$100 of covered charges incurred while covered by this plan. <br /> Rates include the following: Impact: <br /> • Annual Maximum:$1,000 Calendar year per person • +0% <br /> Plan Factors: • Less than 60%employee participation • +5% <br /> • Increase Endodontic/Periodontal coinsurance to 80% • +5% <br /> • Posterior composite(white)fillings • +5% <br /> Pathfinder Value Employee Employee+Spouse Employee+Child(ren) <br /> Family-Employee, <br /> Spouse,Children) <br /> no Ortho <br /> $33.16 $68.19 $69.23 $109.86 <br /> Rates are Valid through December 1,2017 Effective Dates <br /> This is a summary only.For complete details,refer to your Dental Benefits Plan Summary. <br /> We do not provide coverage to:Dental offices,groups with high turnover,or seasonal employment practices. <br /> 10/3/2016 at 12:03pm CDT <br />