North State Bank 2024 Benefits Guide

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NORTH STATE BANK | 2025 BENEFITS GUIDE

Dental:

Plan details below are based on in-network services and providers in the Delta Dental network.

Basic Dental

Enhanced Dental

Lifetime Deductible

$100 per covered person

$100 per covered person

Annual Maximum

$1,500 per covered person

$2,000 per covered person

Carryover Benefit

Participants can carry over $400 of unused benefits if annual expenses were under $800. Carryover benefits can be accumulated up to $1,500 maximum. Exams & Cleaning X-Rays (bite-wing & full mouth) Emergency Pain Fluoride & Sealants to age 16 Space maintainers to age 16 Oral Cancer screening over 40 Fillings & Simple Extractions Periodontics Endodontics Anesthesia Oral Surgery Inlays & Onlays Crowns, Bridges, Dentures Implants

None

Diagnostic & Preventative 100% after Deductible

Exams & Cleaning X-Rays (bite-wing & full mouth) Emergency Pain Fluoride & Sealants to age 16 Space maintainers to age 16 Oral Cancer screening over 40

Basic Service

Fillings & Simple Extractions

80% after Deductible

Major Services

Anesthesia Oral Surgery Periodontics Endodontics Inlays & Onlays Crowns, Bridges, Dentures Implants

50% after Deductible

Orthodontics

Under age 19 $1,500 lifetime limit

Under age 19 $2,000 lifetime limit

50% with no Deductible

Monthly Employee Deduction

Employee & Spouse

Employee & Child(ren)

Employee & Family

Dental Plans

Employee

Dental- Basic Plan

$0.00

$19.82

$28.61

$54.34

Dental- Enhanced Plan

$4.69

$29.15

$41.53

$73.55