Page 12 - Summit Group 2 Benefits Eff 12-1-19

Dental Option:

Lincoln Financial

Rate Information

Per Pay Period Dependent Information

Employee Only $15.53 Summit LTC Management, LLC offers employees the
opportunity to cover their spouse or dependent children.
Employee + 1 $30.28 Children can join or remain on a parent’s dental plan until
age 26. When a child turns 26, they will lose dental coverage
Employee + 2 or More $45.51
on the last day of their birth month. This is an automated
process.

(In-Network) Amount Paid
Type of Service
Out-of-Network is Paid @ 90% of U&C

Preventive Services Covered at 100%; No Deductible

Subject to (individual) $50 Deductible or (family)
Basic Services
$150 deductible; Covered at 80%
Subject to (individual) $50 Deductible or (family)
Major Services
$150 deductible; Covered at 50%
Annual Maximum $2,000

Orthodontia (Under age 19) Covered at 50% to a Lifetime Maximum of $1,500

Type of Service Benefit Description
Oral Exams, Cleanings, X-rays, Sealants, Fluoride
Preventive Services (Type I)
Treatment
Composite Fillings, Extractions, Anesthesia, Sedation,
Basic Services (Type II)
Root Canal, Periodontics

Crowns, Bridges, Oral Surgery, Full or Partial
Major Services (Type III)
Dentures, Inlays and Onlays

Treatments, Exams, X-Rays, Extractions, Study Models
Orthodontia (Type IV)
and Appliances

You have No Waiting Periods when enrolled during
Waiting Periods
your enrollment period.

Annual Maximum Applies January 1 to December 31

NOTE: This is only a brief overview. Please see Benefit Summary for more details.

Website: www.lincolnfinancial.com or Customer Service : 800-423-2765

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