Average Plan

Maximum Coverage…………………$1000.00

Plan Year……………………………..Calendar

Deductible…………………………….$50.00 per year , $150.00/family per year

Payment………………………………UCR, Plan pays lowest alternative treatment

Preventive…………………………… 100%, deductible not waived

Basic…………………………………. 80%

Major………………………………… 50%

Cleanings…………………………… 2 per year

Sealants…………………………….. To age 14

Prosthetic Replacement…………… Replacement age: 5 years

Prior extractions …………………… Not Covered

Full mouth x-rays………………….. Every 3 years

Dependent Coverage………………. To age 19-Full time students to age 23

Orthodontic Coverage……………….$1000.00

Ortho percentage………..50%

Ortho Age Limits ……….To age 19

Accepts Uniclaims……………………Yes

Electronic claims……………………..No

Predetermination …………………….No

Send X-rays………………………… Periodontal services must also include chart

Assignment of Benefits……………… To dentist with valid assignment

………………………….Notes and Limitations………………………………

Sealants to age 14

Sealants on molars only

Fluoride to age 19

Fluoride 2 per year

Plan has waiting period

Panorex x-ray not paid in addition to full mouth x-rays

Posterior Composites ( white-fillings) paid as lower alternative ( amalgam)

Nightguards not covered

Treatment for temoralmandibular joint ( TMJ) dysfunction not payable

Porcelain veneers not covered

Implants not covered

Periodontal surgery paid as major

Diagnostic tomograms, or CT scans not payable