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Plan Number: 6255
Plan Year: September 1 through August 31
Customer Service Number: 800-798-1125
Coverage is effective the first of the month following your date of hire.
Choose any dentist or choose to see a dentist in the network.
| Benefits Paid Based on
Usual & Customary |
Fluoride Treatments (under age 19), X-rays, Cleanings, Periodic Exams
|
|
1st Year |
2nd Year |
Thereafter |
Deductibles -
|
-0- |
-0- |
-0- |
Company Pays - |
100% |
100% |
100% |
|
Simple Extractions, Fillings, Oral Surgery, Root Canals
|
|
1st Year |
2nd Year |
Thereafter |
Deductibles -
|
$50 BY |
$50 BY |
$50 BY |
Company Pays - |
80% |
80% |
80% |
|
Removal of Impacted Teeth, Bridges, Crowns, Dentures, Partials
|
|
1st Year |
2nd Year |
Thereafter |
Deductibles -
|
Not
Covered |
$50 BY
|
$50 BY
|
Company Pays - |
80% |
80% |
Maximum Benefit Year
Type 1, 2 and 3 |
|
$750 |
$1,000 |
$1,500 |
| |
| |
| |
1st Year |
2nd Year |
Thereafter |
Lifetime Deductibles-
|
Not Covered |
Not Covered |
$50 LT |
Company Pays-
|
50% |
Lifetime Benefits- |
$1,000LT |
All benefits and provisions are subject to the terms of the policy issued and any state requirements. If the provisions of the policy and those listed in this flyer do not agree, the policy provisions will rule.
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