|
|
|
| Which Plan? |
Who will be
covered? |
Payment Method |
Biweekly |
Monthly |
Quarterly |
Semi-
Annual |
Annual |
Delta Care
USA HMO* |
Member |
NSA Payroll Allotment |
$8 |
|
|
|
|
| Direct bill from GEBA |
|
|
$52 |
$104 |
$208 |
| Auto Debit from Bank |
|
$17.33 |
$52 |
$104 |
$208 |
Member
Plus One |
NSA Payroll Allotment |
$13 |
|
|
|
|
| Direct bill from GEBA |
|
|
$84.50 |
$169 |
$338 |
| Auto Debit from Bank |
|
$28.17 |
$84.50 |
$169 |
$338 |
Member
Plus Family |
NSA Payroll Allotment |
$18 |
|
|
|
|
| Direct bill from GEBA |
|
|
$117 |
$234 |
$468 |
| Auto Debit from Bank |
|
$39 |
$117 |
$234 |
$468 |
| * Delta Care USA HMO is available in Florida, Georgia, Maryland, Pennsylvania, Texas and Washington, D.C., only |
| |
| Which Plan? |
Who will be
covered? |
Payment Method |
Biweekly |
Monthly |
Quarterly |
Semi-
Annual |
Annual |
Basic
Delta
Dental PPO |
Member |
NSA Payroll Allotment |
$13 |
|
|
|
|
| Direct bill from GEBA |
|
|
$84.50 |
$169 |
$338 |
| Auto Debit from Bank |
|
$28.17 |
$84.50 |
$169 |
$338 |
Member
Plus One |
NSA Payroll Allotment |
$22 |
|
|
|
|
| Direct bill from GEBA |
|
|
$143 |
$286 |
$572 |
| Auto Debit from Bank |
|
$47.67 |
$143 |
$286 |
$572 |
Member
Plus Family |
NSA Payroll Allotment |
$29 |
|
|
|
|
| Direct bill from GEBA |
|
|
$188.50 |
$377 |
$754 |
| Auto Debit from Bank |
|
$62.83 |
$188.50 |
$377 |
$754 |
| |
| Which Plan? |
Who will be
covered? |
Payment Method |
Biweekly |
Monthly |
Quarterly |
Semi-
Annual |
Annual |
Enhanced
Delta
Dental PPO |
Member |
NSA Payroll Allotment |
$20 |
|
|
|
|
| Direct bill from GEBA |
|
|
$130 |
$260 |
$520 |
| Auto Debit from Bank |
|
$43.34 |
$130 |
$260 |
$520 |
Member
Plus One |
NSA Payroll Allotment |
$39 |
|
|
|
|
| Direct bill from GEBA |
|
|
$253.50 |
$507 |
$1,014 |
| Auto Debit from Bank |
|
$84.50 |
$253.50 |
$507 |
$1,014 |
Member
Plus Family |
NSA Payroll Allotment |
$59 |
|
|
|
|
| Direct bill from GEBA |
|
|
$383.50 |
$767 |
$1,534 |
| Auto Debit from Bank |
|
$127.84 |
$383.50 |
$767 |
$1,534 |
* You must be enrolled in the Basic Delta Dental PPO for one (1) year before enrolling in the Enhanded Delta Dental PPO.
Electing direct bill on a biweekly, monthly, quarterly or semi-annual basis will incur a $2.00 service fee. Direct bill on an annual basis will not incur this service fee. |
|
|
 |
|