With this plan you have the freedom to select any dentist you wish. If
you choose to see a participating PPO dentist you will receive a higher
level of reimbursement. You may decide at the time you receive services
whether or not to utilize a participating provider.
| Preferred Dental Network |
Out of Network |
| ANNUAL
DEDUCTIBLE: $25 PER PERSON (MAX. 3/FAM.) Waived for Class I |
ANNUAL
DEDUCTIBLE: $50 PER PERSON (MAX. 3/FAM.) Waived for Class I |
CALENDAR YEAR BENEFIT:
Basic: $1,250 |
CALENDAR YEAR BENEFIT:
Basic: $1,250 |
CLASS I
100% of PPO Schedule - (No deductible) |
CLASS I
90% of PPO - (No deductible) |
CLASS
II
80% of PPO Schedule - (After deductible) |
CLASS
II
70% of PPO Schedule - (After deductible) |
CLASS
III
50% of PPO Schedule - (After deductible) |
CLASS
III
40% of PPO Schedule - (After deductible) |
CLASS
IV
Basic: No Benefit When using a non-network provider /Adult and children orthodontic refer to enhanced benefit schedule |
CLASS
IV
Basic: No Benefit When using a non-network provider
/Adult
and children orthodontic refer to enhanced benefit schedule |
