Page 13 - Allegacy 2017 booklet 8.5x11

Allegacy Benefit Solutions Page 13

Dental Benefits cont’d

 Employees contribute to the dental cost through payroll deductions.
 Dependent children can be covered until the age of 26, regardless
of student status.
 Newborns should be added no later than the age of 2, in order to
keep from being coded as a late entrant
 Annual deductible of $50 per person, $150 per family, applies to Type
2 & 3 services.
 Annual benefit maximum is $1,750, combined from all service types.
 A waiting period of 12 months applies to orthodontia procedures,
excluding initial insureds.
 This is an indemnity plan, therefore members are able to see any
dental provider regardless of network. This plan reimburses at the
90th UCR.

Employees monthly cost for plan year 1/1/17 to 12/31/17:

Employee Only $21.78 Emp + Spouse $65.26
Emp + Child(ren) $87.54 Family $109.52