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)|
|Type I Services||Type II Services||Type III Services|
|Benefit||100% of UCR||80% of UCR||50% of UCR|
|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.
|Coverage||Weekly Deductions||Semi-monthly Deductions|
|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.