Benefit Maximum
Per Person, Per Policy Year $1,000.00
Deductible
Per Person, Per Policy Year $50.00
Family Aggregate Deductible $150.00
Coinsurance Percentage Per Person
Type IV Dental Services 50%
Lifetime Orthodontic Maximum $1,000.00
Only for dependent children under 19
This deductible applies to Type II & III
Services only.
NO WAIT FOR TYPES I, II, III
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Elite 75 Schedule Plan
Bi-Weekly Deduction
Individual $14.00
Individual & one dependent $23.00
Family $33.00
Monthly Bank Draft Rate
Individual $30.33
Individual & one dependent $49.83
Family $71.50
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| Type I Dental Services |
Maximum Covered
Expense |
|
·Oral Exam, 1 in 6 months |
$21.00 |
Fluoride Treatment – 2 in any 12 month
only for children under age 16 $
(Excluding prophylaxis) |
$13.00 |
Routine Dental Cleanings, adult/child
1 in any 6 months |
$32.00/$26.00 |
| Sealant, per permanent molar |
$16.00 |
| X-Rays, bitewing - 2 films |
$16.00 |
Panoramic X-Ray
(once every 3 years) |
$44.00 |
| Type II Dental Services, Including:
|
| Amalgam Fillings 1-3 surfaces
|
$34-$54
|
| Resin Fillings 1-3 surfaces ant
|
$37-$58
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| Sedative Filling
|
$34.00
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| Molar Root Canal
|
$273.00
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| Surgical removal of erupted tooth
|
$76.00
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| Type III Dental Services, Including: |
| Crown-porc. fused to noble metal |
$224.00 |
| Crown-full cast high noble
metal |
$236.00 |
| Complete denture maxillary |
$261.00 |
| Complete denture mandibular |
$259.00 |
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Type IV Orthodontic Dental Services
Only for dependent children 18 or younger
Type IV………...12 month Waiting Period
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Other Policy Provisions
Predetermination
If covered dental expenses for a procedure are expected to be more than $200 it is recommended that you send a dental treatment plan prior to beginning treatment for preauthorization.
Eligibility
Full-time member, spouse and unmarried dependent children less than age 19, or less than age 25 if a full-time student. Dependent eligibility variation exists in some states. Please refer to your Group Policy.
This is a brief description only. It is not a Certificate of Coverage. Please see the Group Policy for a complete list of covered dental services and the Maximum Covered Expense
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