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Dental Plan

Schedule of Benefits
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.

Dental Plan Premiums
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
Benefit 50% of UCR
Waiting Periods None
Benefit Maximum $2,000.00 per Lifetime per Covered Person
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