Dental Rate Sheet
Proposed Coverage: Level 1–Basic Level 2–Intermediate Level 3-Plus
Age Basic Intermediate Plus
18-30 15.50 26.50 35.40
31-40 15.50 26.50 42.50
41-50 15.50 26.50 51.00
51-60 15.50 26.50 61.20
61-64 15.50 26.50 67.30
65-70 19.50 32.50 75.00
Per adult rate if spouse is covered
Age Basic Intermediate Plus
18-30 13.95 23.85 31.86
31-40 13.95 23.85 38.25
41-50 13.95 23.85 45.90
51-60 13.95 23.85 55.08
61-64 13.95 23.85 60.57
65-70 17.55 29.75 67.50
Child Basic Intermediate Plus
1 child 13.20 21.90 28.30
2 children 26.40 43.80 56.60
3 children 39.60 65.70 84.90
4 children 52.80 87.60 113.20
Call Ensurity Group at 855-332-7148for details
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