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EP510 Schedule
MAXIMUM BENEFITS
PREDETERMINATION
SUMMARY OF BENEFITS
| Partial Listing of |
In-Network |
Out-of-Network |
| Covered Services |
Reimbursements* |
Reimbursements |
| |
 |
|
|
|
| Type I Diagnostic & Preventive |
100% |
100% |
| |
|
Oral Examination (once per six months)
Prophylaxis (cleaning, once per six months)
Topical Fluoride (children under 16,once per 12 months)
X-Rays (limitations may apply)
Sealants (once per 3 years for children under age 16, for non carious
molars only)
Space Maintainers (for children under age 16) |
| |
| Type II Basic Services |
85% |
85% |
| |
|
Simple Restorative (amalgam, synthetic, or composite fillings)
Emergency Palliative Treatment
Tooth Extraction
Impacted Wisdom Teeth Extraction
Endodontics (root canals)
Periodontics (includes treatment of diseases of the gums) |
| |
| Type III Major Services |
50% |
50% |
| |
|
Major Restorative (crowns/inlays/onlays)
Bridge, Denture Repair
Prosthetics (bridges and dentures)
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MAXIMUM BENEFITS
Insured Individual and Dependents
| |
In-Network |
Out-of-Network |
| |
Reimbursements |
Reimbursements |
| |
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| Lifetime |
|
Type I, II, III |
Unlimited |
Unlimited |
| |
| Calendar Year |
|
Type I, II, III |
$1,000 |
$1,000 |
|
| Impacted Wisdom
Teeth Extractions
|
$1,000 |
$1,000 |
| |
| Deductible** |
|
Type I |
None |
None |
|
Type II, III |
$25
|
$25
|
| |
A complete description of the coverage, including limitations on
certain procedures, is found in the Schedule of Benefits and Certificate
of Group Dental Insurance.
*Coverage based on contracted fees for the Preferred Provider
Network.
**Maximum of 3 per family.
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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 in
prior to beginning treatment, send preauthorization to:
CompBenefits
P.O. Box 8236
Chicago, IL 60680-8236
You and/or your dentist will be notified of the benefits payable based
upon the Dental Treatment Plan.
This information contains a brief description of the plan.
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