Low End Plan

Maximum ………………………….$750.00

Plan Year…………………………..Calendar

Deductible………………………….$50.00

Payment……………………………Fee Schedule

Preventive………………………….100%,

Basic…………………………………80%

Major………………………………...50%

Cleanings………………………….. 2 per year

Sealants…………………………….to age 14

Prosthetic Replacement………….. Replacement every 5 years

Prior Extractions………………….Not Covered

Full mouth x-rays…………………Every 3 years

Dependent Coverage……………...To age 19

Orthodontic Coverage…………….$750.00

Ortho percentage 50%

Ortho Age limit…………To age 19

Accepts uniclaims…………………Yes

Electronic Claims………………….No

Predetermination ………………….No

Send X-rays……………………… All Major treatment

Assignment of Benefits…………….Dentist must be listed as provider

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

Plan has waiting periods

Sealants on molars only

Sealants to age 14

Fluoride to age 19

No benefits if seen by a non-participating dentist

Implants not covered

Porcelain veneers not covered

Nightguards not covered

Treatment for temporalmandibular joint ( TMJ) dysfunction not payable

Posterior Composite ( white fillings) paid as lower alternative ( amalgams )

Diagnostic tomograms or CT scan not payable

Panorex not payable in addition to full mouth x-rays