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Elite Preferred 505 Dental PPO Overview
The PPO 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
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| Type I -
Diagnostic & Preventive Services |
Reimbursement |
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In
Network |
Out of Network* |
Oral Exam
Prophylaxis
Topical Flouride
X-Rays
Sealants
|
100% |
100% |
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| Type II - Basic Services |
Reimbursement |
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| |
In
Network |
Out of Network* |
Simple Restorative
Space maintainers
Non-Surgical Tooth Extraction
Non-Surgical Periodontics
|
80%
|
80% |
|
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| Type III - Major Services |
Reimbursement |
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In
Network |
Out of Network* |
Major Restorative
Bridge, Denture Repair
Prosthetics
|
50% |
50% |
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| Type
IV - Orthodontics |
Reimbursement |
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In
Network |
Out of Network* |
Dependent Children 18 years of age or younger
|
50% |
50% |
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MAXIMUM BENEFITS |
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In
Network |
Out of Network* |
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Lifetime
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Type I, II, III
|
Unlimited
|
Unlimited
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Type IV
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$1000
|
$1000 |
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Calendar Year Maximum (per person)
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Type I, II, III
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$1000
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$1000
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Type IV
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$500
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$500 |
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Deductible per person; maximum 3 per family
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Type I
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None
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None
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Type II, III, IV
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$50
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$50 |
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Exclusions
and Limitations |
*Coverage based on usual, customary, and reasonable fees.
Certain exclusions and limitations apply.
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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. For a complete listing of benefits and
exclusions and limitations, please reference your certificate of coverage.
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