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Dental Plan

Schedule of Benefits

This Dental plan is no longer a closed plan and members can be added or changed during annual open enrollment periods. Enrollment is offered when employee is first eligible or if there is a HIPAA Enrollment Event as defined in the Plan Document/Summary Plan Description.

NEW - Type III dental service tiers have been eliminated and will be paid at 50%.

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 $1,000.00 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.

Dental Plan Premiums
Coverage Weekly Deductions Semi-monthly Deductions
Employee Only $1.86 $4.03
Employee + 1 Dependent $5.92 $12.83
Employee + 2 or more Dependents $11.92 $25.83
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Please Note: Flexible Spending Accounts and Vision Insurance are not administered by TLC.

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