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c4f e c� <br />Deductible <br />Single <br />Family <br />Dependent Age Limit <br />Waived for Preventive <br />Preventive Services <br />Basic Services <br />Major Services <br />Annual Maximum <br />Orthodontia <br />Lifetime Maximum <br />Benefit Detail <br />Endodontic <br />Periodontal <br />Oral Surgery <br />Out of Network <br />Reimbursement <br />Rate Guarantee <br />Employee 21 <br />EE/Spouse 15 <br />EE/Child(ren) 4 <br />Family 33 <br />TOTAL 73 <br />Monthly Premium <br />Annual Premium <br />$ +/- Current <br />% +/- Current <br />This illustration is intended to outline the basic plan and is not intended to describe the contract provision. <br />Each employee will receive a plan booklet which will outline in detail the plan provisions and limitations. <br />Should there be a discrepancy between this outline and the plan document, the plan document prevails. <br />