City of Tallahassee
Dental Options
DHMO CS25D8
  Overview
  Schedule of Benefits
  FAQs

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ELITE PREFERRED 505 w/ortho
  Overview
  Schedule of Benefits
  FAQs
  Search for Providers
  Claim Form
ELITE CHOICE 405 w/ortho
  Overview
  Schedule of Benefits
  FAQs
  Claim Form
Vision Option
  Plan Overview
  LASIK Benefits
 
Dental/Vision Members
  MyCompBenefits
  Vision Certificate of Benefits
 
 
  Contact Information


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:

bulletFreedom to choose any dentist
bulletQuick claims turnaround
bulletNational coverage


Type I - Diagnostic & Preventive Services Reimbursement
In
Network		 Out of Network*
  • Oral Exam
  • Prophylaxis
    •
  • Topical Fluoride
  • X-Rays
  • Sealants

    •      		 100% 80%
    Type II - Basic Services Reimbursement
      In
    Network    		 Out of Network*
  • Simple Restorative
  • Space maintainers
  • Non-Surgical Tooth Extraction
  • Non-Surgical Periodontics

    •       		80%

    50%

    Type III - Major Services Reimbursement
    (12 month waiting period)** In
    Network    		 Out of Network*
  • Major Restorative
  • Bridge, Denture Repair
  • Prosthetics
     
    		•  50% 50%

         		    
    Type IV - Orthodontics Reimbursement
    (12 month waiting period)** In
    Network    		 Out of Network*

  • Dependent Children 18 years of age or younger
    •

    		50% 50%

         		    
    MAXIMUM BENEFITS    
      In
    Network    		 Out of Network*

    Lifetime
       



        Type I, II, III

    Unlimited
     

    		 Unlimited

        Type IV
       

    $1000 

    		$1000 

    Calendar Year Maximum (per person)
       



        Type I, II, III

    $1000
     

    		 $1000

        Type IV
       

       $500 

    		   $500 

    Deductible per person; maximum 3 per family
       



        Type I

    		None
         		 None

        Type II, III, IV
       

    $50 

    		$50 


    Exclusions
    and Limitations

    		 *Coverage based on usual, customary, and reasonable fees.

    **Time served on the employer's immediately preceding group dental plan may be credited towards this plan's waiting periods, subject to Underwriting approval.

    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. For a complete listing of benefits and exclusions and limitations, please reference your certificate of coverage.