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| Annual Deductible | $50.00 (Type II and Type III only) | ||
|---|---|---|---|
| Coinsurance Percentages | |||
| Type I Services | Type II Services | Type III Services | |
| Benefit | 100% of UCR | 80% of UCR | 50% of UCR |
| Waiting Periods | None | None | None |
| Benefit Maximum | $1,500.00 per Policy Year per Covered Person | ||
UCR - Usual, customary and reasonable - Commonly charged fees for dental services in a certain area.
The above information is provided as a summary only. For a detailed list of Type I, II, and III services, please refer to the Summary Plan Document.
| Coverage | Weekly | Semi-monthly |
|---|---|---|
| Employee Only | $2.05 | $4.43 |
| Employee + 1 Dependent | $6.51 | $14.11 |
| Employee + 2 or more Dependents | $13.11 | $28.41 |
| Orthodontia | |
|---|---|
| Benefit | 50% of UCR |
| Waiting Periods | None |
| Benefit Maximum | $2,000.00 per Lifetime per Covered Person |
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Please Note: Flexible Spending Accounts and Vision Insurance are not administered by TLC.
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