Page 10 - 2024-25 Gas Clip Technologies Benefit Guide EXECUTIVES

Dental Options:

Equitable

2024-25 Rate Information
Dependent Information
Per Pay Period Semi-Monthly
Gas Clip Technologies offers employees the
Employee Only $ 3.64 opportunity to cover their spouse and

Employee + Spouse $ 7.12 dependent children. Children can join or remain
on a parent’s dental plan until age 26. When a
Employee + Child(ren) $ 9.26 child turns 26, they will lose dental coverage on
Employee + Family $13.79 the last day of their birth month.

Equitable Dental $1,750 CY (Calendar Year) Max
Type of Service
Non-Network Dentists - Reimbursed at 90th U&C

Calendar Year Deductible Individual $50 / Family $150

Preventive Services Covered at 100%; No Deductible
Basic Services Subject to $50 Deductible; Covered at 80%

Major Services Subject to $50 Deductible; Covered at 50%

Annual Maximum $1,750

R&C Plan - pays 90% of the Usual and Customary charge for the area
Out of Network
where services are provided.
Orthodontia - Not Covered
Adults & Children < 19

Type of Service Benefit Description

Routine Oral Examinations, Bitewing X-rays, 2 annual Routine cleanings,
Preventive Services
Routine Cleanings, Fluoride Treatments Sealants.
Services Include: Basic Restorative Services (amalgam fillings on all
teeth, resin based composite fillings on anterior teeth), Simple
Basic Services
Extractions, Surgical Extractions and Removal of Impacted Teeth, Oral
Surgery,

Crowns, Inlays, Onlays and most related services, Bridges, Full and
Partial Dentures, Denture Reline and Rebase Services, Implants and
Major Services related services. Endodontics (including Root Canal Treatment),4 an-
nual Periodontal Cleanings, Non-surgical Periodontal Therapy-Scaling
and Root Planning, Periodontal Surgery. Missing tooth clause applies.
Please note: This summary is intended for general information purposes.
It is not a guarantee of benefits. Please reference the SBC or contact the carrier for specific details.

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