Monthly Premium Rates Effective Jan 1, 2018 through Dec 31, 2018 Employee Employee + 1 Employee + 2 Employee + 3 or more

$39.58 $77.23 $116.42 $145.25

Minot Public Schools Premier Plan The following is a brief outline of dental benefits offered through your employer which is intended to help you understand your benefits and does not guarantee coverage. For a complete list of covered benefits please refer to your employee booklet/certificate you will receive after enrollment or contact TDA. Provider Network/Reimbursement Class 1 -Preventative Services -Oral Examinations (2 every 12 months) -Cleanings (2 every 12 months) -X-Rays -Palliative Emergency Treatment Class 2 -Basic Services -Restorations (fillings) -Simple Extractions Class 3 -Major Dentistry -Oral Surgery -Endodontics (root canal therapy) -Periodontics (treatment of gum tissue) -Crowns -Dentures -Bridges -Other Prosthetic Services Class 4 -Orthodontic Services Deductible Annual Maximum per Plan Year Lifetime Orthodontic Maximum

Class 3 Waiting Period: Class 4 Waiting Period:

12 Months 12 Months

Find a Provider https://www.tdadental.com/providers/find_provider.php

TDA PPO Network

Out of Network

100%

100%

80%

80%

50%

50%

50%

50%

$100 Lifetime applies to Class 1, Class 2 and Class 3 $1,500.00 applies to Class 1, Class 2 and Class 3 $1,000.00 applies to children up to age 19 Total Dental Administrators, Inc 2111 E. Highland Avenue, Suite 250 Phoenix, Arizona 85016 Toll Free: (888) 422-1995 Web: www.TDAdental.com Email: [email protected]