| Benefit Summary * |
| Opt A - Non Vol (5-99 lives) |
| ( in effect on 11/3/2002 ) |
| |
|
| General |
|
| Deductible |
None |
| Maximum |
Unlimited |
| Waiting Period |
None |
| |
|
| Diagnostic |
|
| Office Visit |
Covered in full |
| X-rays - complete set |
Covered in full |
| |
|
| Preventive |
|
| Prophylaxis |
1 treatment per 6 mo. period covered in full |
| Space maintainer |
$40 copay |
| |
|
| Restorative |
|
| Amalgam - primary |
Covered in full |
| Amalgam - permanent |
Covered in full |
| |
|
| Endodontics |
|
| Root canal - anterior |
$75 copay anterior, $120 copay bicuspid (excluding final
restoration) |
| Root canal - molar |
$180 copay (excluding final restoration) |
| |
|
| Periodontics |
|
| Gingivectomy - per quadrant |
$125 copay |
| Periodontal scaling - per quadrant |
$45 copay |
| |
|
| Oral Surgery |
|
| Extraction - single tooth |
$6 copay |
| Extraction impacted |
$40 copay soft tissue; $60 copay partially bony; $80 copay
completely bony |
| |
|
| Adjunctive |
|
| Local anesthesia |
Covered in full |
| Broken appt. fee |
$10 per 15 min. of appt. time if no 24 hr. notice |
| General anesthesia |
Not covered |
| |
| Crown/Bridge |
| Porcelain/Ceramic |
$195 copay |
| Inlay - metallic 1 surface |
$130 copay |
| |
|
| Prosthodontics |
|
| Upper or lower partial |
$275 copay |
| Upper or lower complete |
$225 copay |
| |
|
| Orthodontics |
|
| Plan, x rays, study model |
$350 copay for start up fees (excludes records) |
| Limited treatment |
$1600 copay children up to age 19; $1800 copay for adults.
(24 mos.) |
| Full treatment |
$1600 copay for children to age 19; $1800 copay adults.
(24 mos.) |
| |
|
| Notes: |
|
| Dependent orthodontic benefits extended to age
23 for full-time students. |
| * Please refer to certificate for full benefit
descriptions and limitations |
