Page 11 - Summit LTC Management LLC - Benefit Guide GROUP 1 Effective Dec 1, 2019 Revised July 2020

Dental Option:

Lincoln Financial

Rate Information Dependent Information
Per Pay Period Semi-Monthly Monthly
Summit LTC Management, LLC offers employees

Employee Only $ 15.53 $ 31.05 the opportunity to cover their spouse or
dependent children. Children can join or remain
Employee + 1 $ 30.28 $ 60.56 on a parent’s dental plan until age 26. When a
child turns 26, they will lose dental coverage on
Employee + 2 or More $ 45.51 $ 91.02
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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