Page 16 - Omega Benefits Guide
P. 16
Voluntary Dental Information
Companion Dental Benefits
Benefit Highlights Modified Dental Essentials
100% of UCR Covered
Diagnostic &
Deductible is waived
Preventative Services
80% of UCR Covered, after deductible
Basic Services
Major Services 50% of UCR Covered, after deductible
Annual Individual $50 Per Person
Deductible Waived for diagnostic/preventative
Annual Individual $150 Family Cap
Deductible Waived for diagnostic/ preventative
Annual Benefit Maximum $2000 per insured
Endodontics Covered as Major Service
Periodontics Covered as Major Service
Lifetime Maximum 50% up to $1,000 Child only;
Orthodontia
Deductible does not apply
You must be insured for 12 months before any Major or
Timely Entrant
Orthodontia Services will be covered by the plan
Late Entrant Waiting
One year from effective date
Period
Dependent Eligibility Legal Spouse & Dependent Children to age 26
*Usual Customary
90th
Reasonable Charge (UCR)
*UCR is defined as the amount paid for a medical service in a geographic area based on what
providers in the area usually charge for the same or similar medical service. It is sometimes
used to determine the allowed amount.
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