Page 92 - 2023 Down East Wood Ducks - Benefits Guide.docx_Neat

APPENDIX D-2

[Minor League Front Office Plan] High Option (w/ Orthodontics)

This program generally pays 100% of costs up to the maximum allowable charge for Class I
(Diagnostic/Preventive) Services, 80% of costs up to the maximum allowable charge for Class II (Basic)
Services, and 50% of the costs up to the maximum allowable charge for Class III (Major) Services and
Orthodontics. Class II and Class III Services are covered after a $50 per member deductible (not to exceed
$150 per family) and are subject to a $2,000 annual maximum per person. Class I Services do not count
toward your annual maximum. Orthodontics are subject to a $1,500 lifetime maximum per person.
Orthodontics are also limited to dependent children under age 19. Additional frequency limitations apply
to covered services.
You may visit any dentist of your choosing, but note that in-network dentists accept the maximum allowable
charge as payment in full for covered services. This means that if an out-of-network dentist performs a
covered service, you may be billed for any difference between what the program allows and the out-of-
network dentist’s fee. Maximums and deductibles described above apply to the combination of services
received from in-network and non-network dentists. Please refer to the benefits booklet for more
information.

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