HSU DENTAL INSURANCE PREMIUMS CY 2004 Employee Employee Full Family Employee & Spouse Only (plus 1 or more children) Individual One parent Family Family Insured & Spouse BCBS - Dental Indemnity USA $28.30 $57.70 $97.20 $56.50 Region 2 Gold Plan AFLAC - Dental Insurance Level One $18.90 $34.40 $45.40 $30.40 w/Orthodontic Rider to age 15 $29.50 $29.50 Total Premium $18.90 $63.90 $74.90 $30.40 Level Two $22.90 $39.90 $53.90 $36.90 w/Orthodontic Rider to age 15 $29.50 $29.50 Total Premium $22.90 $69.40 $83.40 $36.90 For new employees:
(1) You may only enroll in the BCBS (BlueCross BlueShield) dental plan within the first 30 days of your employment. Additionally, there will be an open enrollment for the BCBS dental plan during November 2004 for coverage beginning January 1, 2005.
(2) You may enroll in either one of the AFLAC dental plans anytime.
(3) You may flex dental insurance premiums for BCBS and AFLAC plans during your first 30 days of employment and again for plans effective January 1, 2005.
05/12/2004