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| Members | Summary of BenefitsBelow is a brief description of the Elite Choice 400 (with ortho) plan. 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 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. ***Maximum of 3 per family.
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| Coverages | |||
| Type I Diagnostic & Preventative | 100% | ||
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Oral Examination (once per six months) Prophylaxis (cleaning, once per six months) Topical Flouride (children under 16, once per 12 months) |
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| Type II Basic Services | 80% | ||
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Simple Restorative (amalgam, synthetic, or composite fillings) 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) |
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| Type III Major Services (12 month waiting period**) |
50% | ||
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Major Restorative (crowns/inlays/onlays) Bridge, Denture Repair Prosthetics (bridges and dentures) Emergency Palliative Treatment Tooth Extraction Endodontics (root canals) Periodontics (includes treatment of diseases of the gums) |
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| Type IV Orthodontics (12 month waiting period**) |
50% | ||
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Dependent children 18 years of age or younger | ||
| MAXIMUM BENEFITS | |||
| Insured Individual and Dependents | |||
| Lifetime | |||
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Type I, II, III | Unlimited | |
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Type IV | $1,000 | |
| Calendar Year | |||
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Type I, II, III | $1,000 | |
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Type IV | $500 | |
| Deductible*** | |||
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Type I | $50 | |
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Type II, III, IV | $50 | |
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