PESC Administrators

Dental Plan Options
Standard Value Plan (100%-80%-50% with $1,000 annual maximum)
Standard Value Plan Plus (100%-80%-50% with $1,500 annual maximum)
Elite Value Plan Plus (100%-90%-60% with $1,500 annual maximum)
Value EPO Plan Plus (100%-90%-60% in- network only with $1,500 annual maximum)
Custom Dental Plan :

Dental PPO Options
Passive PPO (benefits are the same in and out of network = least cost savings)
Active Incentivized PPO (benefits are better in network = greater cost savings)

Maximum Allowable Charge (MAC) for Out of Network Services
MAC is 90^th percentile of NDAS = least cost savings
MAC is 80^th percentile of NDAS = some cost savings
MAC is 70^th percentile of NDAS = more cost savings
MAC is PPO fee schedule = maximum cost savings

Annual Deductibles		Orthodontia
None $25 per employee/$75 max per family $50 per employee/$150 max per family Other :		None Children to age 18; $ lifetime max Adults; $ lifetime maximum

Please complete the second page.

Broker Fee: $ per employee per month

Current Dental Insurance Carrier:

Current in force dental premiums

Renewal dental premiums

Employee	$
Employee + Spouse	$
Employee + children	$
Family	$

Employee	$
Employee + Spouse	$
Employee + children	$
Family	$

Please submit with complete census and dental claims experience if available.

Census Information		Dental Claims Experience

555 W. Shaw Ave., Suite C-1
Fresno, CA 93704

(866) 777-1320
(559) 256-1320
559.256.1321 fax