Page 12 - P&A Group Benefits Enrollments Guide

Dental

Companion Life Dental Benefits

Benefit Highlights Low Plan Buy Up Plan

100% UCR
100% UCR
Cleanings (2 per 12
Type 1 Procedures: Cleanings (2 per 12 months),
months), Oral Exams,
Diagnostic & Oral Exams, Bitewing X-rays
Bitewing X-rays (1 per 12
Preventative Services (1 per 12 months)
months)

80% UCR
80% UCR
Space Maintainers,
Space Maintainers, Fillings,
Type 2 Procedures: Basic Pain Treatment, Sealants, Fillings, Pain Treatment,
Services Sealants, Full Mouth X-
Full Mouth X-rays
rays

50% UCR
0% Anesthesia, Endodontics,
Simple and Surgical
Extractions, Oral Surgery,
N/A Periodontics, Crowns,
Type 3 Procedures: Major
Inlays, Onlays, Dentures,
Services
Bridges, Implants

12 month waiting period
for Late entrants and New
Hires
Individual: $50 per plan year $100 Lifetime limit (Per
Family: $150 per plan year individual) applies to all
Deductible
Deductible applies to Basic services
Services

Plan Year Maximum $1,000 $1,000

Please refer to the policy for comprehensive benefit details. Payment is based upon allowable charges
in the area in which any service is rendered. Any dentist charge above the allowable charge is not a
covered expense.

Dental benefits are on a Plan Year basis from January 1 to December 31.
Dependent children can be covered up to age 26, regardless of student status.

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