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Dental Gold Plans

Gold 1 Benefits Child Adult
Deductible Amount $20 $50
Out-of-Pocket (OOP) Maximum $700 Unlimited
Plan Year Maximum None $1,500
What the employee pays after meeting the deductible
Preventive and Diagnostic 0% 0%
Minor Restorative Services 20% 20%
Major Restorative Services 50% 50%
Waiting Period
Minor Restorative Services None None
Major Restorative Services None None

Gold 2 Benefits Child Adult
Deductible Amount $20 $50
Out-of-Pocket (OOP) Maximum $700 Unlimited
Plan Year Maximum None $1,500
What the employee pays after meeting the deductible
Preventive and Diagnostic 0% 0%
Minor Restorative Services 20% 20%
Major Restorative Services 50% 50%
Waiting Period
Minor Restorative Services None None
Major Restorative Services None None

Gold 3 Benefits Child Adult
Deductible Amount $20 $50
Out-of-Pocket (OOP) Maximum $700 Unlimited
Plan Year Maximum None $2,000
What the employee pays after meeting the deductible
Preventive and Diagnostic 0% 0%
Minor Restorative Services 20% 20%
Major Restorative Services 50% 50%
Waiting Period
Minor Restorative Services None None
Major Restorative Services None None

Gold 4 Benefits Child Adult
Deductible Amount $20 $50
Out-of-Pocket (OOP) Maximum $700 Unlimited
Plan Year Maximum None $2,000
What the employee pays after meeting the deductible
Preventive and Diagnostic 0% 0%
Minor Restorative Services 20% 20%
Major Restorative Services 50% 50%
Waiting Period
Minor Restorative Services None None
Major Restorative Services None None

Gold V1 Benefits Child Adult
Deductible Amount $20 $50
Out-of-Pocket (OOP) Maximum $700 Unlimited
Plan Year Maximum None $1,500
What the employee pays after meeting the deductible
Preventive and Diagnostic 0% 0%
Minor Restorative Services 20% 20%
Major Restorative Services 50% 50%
Waiting Period
Minor Restorative Services None None
Major Restorative Services None 12 months

Gold V2 Benefits Child Adult
Deductible Amount $20 $50
Out-of-Pocket (OOP) Maximum $700 Unlimited
Plan Year Maximum None $1,500
What the employee pays after meeting the deductible
Preventive and Diagnostic 0% 0%
Minor Restorative Services 20% 20%
Major Restorative Services 50% 50%
Waiting Period
Minor Restorative Services None None
Major Restorative Services None 12 months

Gold V3 Benefits Child Adult
Deductible Amount $20 $50
Out-of-Pocket (OOP) Maximum $700 Unlimited
Plan Year Maximum None $2,000
What the employee pays after meeting the deductible
Preventive and Diagnostic 0% 0%
Minor Restorative Services 20% 20%
Major Restorative Services 50% 50%
Waiting Period
Minor Restorative Services None None
Major Restorative Services None 12 months

Gold V4 Benefits Child Adult
Deductible Amount $20 $50
Out-of-Pocket (OOP) Maximum $700 Unlimited
Plan Year Maximum None $2,000
What the employee pays after meeting the deductible
Preventive and Diagnostic 0% 0%
Minor Restorative Services 20% 20%
Major Restorative Services 50% 50%
Waiting Period
Minor Restorative Services None None
Major Restorative Services None 12 months

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