Page 14 - 2015 OE Sample Guidebook
P. 14
DENTAL COVERAGE
If you enroll in a [Client] Medical plan you will automatically be
enrolled in the Dental Plan. You have the option to waive the Dental
coverage (see page 13 for premium reductions related to the Dental
Opt Out). You and your covered dependents are required to satisfy an
annual deductible each calendar year before beneits will be paid for
General and Major Restorative Services.
The deductible is met when your out-of-pocket expenses for covered
charges reach $50 for the calendar year. The family deductible is
satisied when covered members have incurred a combined total of
$100 in covered charges in a calendar year.
Your dental coverage provides for an annual checkup which includes
an oral exam, routine cleaning, and bitewing x-rays at no cost to you as
long as charges are within reasonable and customary limits. As dental
health is very important to your well being, we strongly encourage you
to use this beneit feature.
The plan covers the following comprehensive services:
Preventive and Diagnostic Services
General and Major Restorative Services
Orthodontics
Plan Features Coverage
Annual Maximum $1,000
(per covered individual)
Annual Deductible $50 Individual
(Does not apply for orthodontic services, $100 Family
preventive, or diagnostic services)
Preventive and Diagnostic Services 100% *
Oral exam, luoride treatment for children,
routine cleaning, bitewing x-rays
General Restorative Services Plan pays 80% after
Fillings, oral surgery, endodontics, sealants deductible *
Major Restorative Services Plan pays 50% after
Crowns, bridges, dentures deductible *
Orthodontic Services Plan pays 50%; $1,000
(eligible children up to age 19) lifetime maximum per
covered individual
* Subject to reasonable and customary limits
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If you enroll in a [Client] Medical plan you will automatically be
enrolled in the Dental Plan. You have the option to waive the Dental
coverage (see page 13 for premium reductions related to the Dental
Opt Out). You and your covered dependents are required to satisfy an
annual deductible each calendar year before beneits will be paid for
General and Major Restorative Services.
The deductible is met when your out-of-pocket expenses for covered
charges reach $50 for the calendar year. The family deductible is
satisied when covered members have incurred a combined total of
$100 in covered charges in a calendar year.
Your dental coverage provides for an annual checkup which includes
an oral exam, routine cleaning, and bitewing x-rays at no cost to you as
long as charges are within reasonable and customary limits. As dental
health is very important to your well being, we strongly encourage you
to use this beneit feature.
The plan covers the following comprehensive services:
Preventive and Diagnostic Services
General and Major Restorative Services
Orthodontics
Plan Features Coverage
Annual Maximum $1,000
(per covered individual)
Annual Deductible $50 Individual
(Does not apply for orthodontic services, $100 Family
preventive, or diagnostic services)
Preventive and Diagnostic Services 100% *
Oral exam, luoride treatment for children,
routine cleaning, bitewing x-rays
General Restorative Services Plan pays 80% after
Fillings, oral surgery, endodontics, sealants deductible *
Major Restorative Services Plan pays 50% after
Crowns, bridges, dentures deductible *
Orthodontic Services Plan pays 50%; $1,000
(eligible children up to age 19) lifetime maximum per
covered individual
* Subject to reasonable and customary limits
14
