Elite 75 Schedule Overview

The scheduled indemnity plan offers a variety of benefits with set reimbursement amounts. You pay the provider for services at the time of your appointment. Claim payments are then made to you or your provider. The plan features:
 

	Freedom to choose any dentist
	Quick claims turnaround
	National coverage

 

Type I – Preventive Services	Patient Pays
Initial Exam X-Rays (bitewings) – two films Semi-Annual Cleaning Sealant - per tooth	$21.00 $16.00 $32.00 $16.00
Type II – Basic Services	Patient Pays
One surface silver filling, primary Two surface white filling, anterior Single tooth extraction Surgical removal of erupted tooth Molar root canal therapy	$34.00 $47.00 $38.00 $76.00 $273.00
Type III – Major Services	Patient Pays*
Porcelain crown (high noble) Porcelain bridge (pontic, high noble) One surface inlay, metallic Complete upper dentures	$226.00 $224.00 $147.00 $261.00
Type IV – Orthodontics	Patient Pays*
(12 month waiting period) Dependent children 18 years of age or younger	50%

Calendar Year Deductible	None
Individual Family Aggregate	$50.00 $150.00
Annual Maximum Benefit
Individual	$1,000
Pre-Existing Condition Exclusion Exclusions and Limitations	Some pre-existing conditions are not covered. Certain exclusions and limitations apply.

This schedule shows only a few of the covered procedures. Please see your Benefit Administrator for a complete schedule. This schedule is intended for comparison purposes only. The benefits for each plan will be determined by the contract.