Page 10 - Walter Robbs 2018 Benefit Guide
P. 10
Dental Benefits
Group # 907-14-02704-000
Companion Life
100% UCR
• Oral Exams (two per 12 months)
Type I Procedures: • Bitewing X-rays (one per 12 months)
Preventive Services • Space Maintainers
• Pain Treatment
• Sealants
• Full Mouth X-rays
80% UCR after Deductible
• Fillings
•
Type II Procedures: Anesthesia
Basic Services • Simple and Surgical Extractions
• Endodontics
• Oral Surgery
• Periodontics
50% UCR after Deductible
• Crowns
• Inlays
Type III Procedures:
• Onlays
Major Services
• Dentures
• Bridges
• Implants
• Perio Trays
50% UCR
Type IV: Orthodontic Services • Up to age 19
• $1,000 lifetime maximum per person
Waiting Periods 12 month waiting period for Orthodontia
$50 per individual
Plan Year Deductible
$150 per family
Plan Year Maximum $1,000 per individual
Dental Plan Reimbursement is subject to Usual Reasonable & Customary (UCR) Charges. Plan
th
reimburses at 90 percentile.
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