Page 15 - GBS OE Brochure - Generic Hospitality

DENTAL BENEFITS
Good oral care enhances overall physical health, appearance and mental well-being. Problems with the teeth and gums are common and easily treated health problems. Keep your teeth healthy and your smile bright with the ABC Company Dental Bene t Plan.
UHC
PPO
DHMO
Bene t Plan Details
In-Network
Out-of-Network
In-Network
Deductible (Annual)
$50 Individual / $100 Family
None
Class I - Preventive & Diagnostic Care Oral Exams, Routine Cleanings, Sealants, Fluoride Application
100% (Deductible Waived)
None
Class II -
Basic Restorative Care - Filings,
Emergency Care to Relieve Pain, Root Canal Therapy/Endodontics, Oral Surgery, Periodontal Scaling and Root
Planing, Surgical Extractions of Impacted Teeth
80% after Deductible
80% after Deductible
See Patient Charge Schedule
Magor Restorative Care - Inlays, Onlays, Crowns, Fixed Partial Dentures (Bridges)
50% after Deductible
50% after Deductible
See Patient Charge Schedule
Class IV - Orthodontia
50% (Adult and Child)
Included - See Patient Charge Schedule
Out-of-Network Reimbursement
N/A
Based on 90% R&C
N/A
N/A
Orthodontia Lifetime Maximum
$1,500
Unlimited
Annual Maximum Bene t
Year 1: $2,500 Year 2: $2,600 Year 3: $2,700 Year 4: $2,800
Unlimited
15