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Plan 1 - Waiting Period Plan
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Plan 2 - Graded Benefit Plan
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Class A - Preventive Services
Initial & Periodic Exams (2 per year),
X-Rays, Cleanings (2 per year)
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Class A - Preventive Services
Initial & Periodic Exams (2 per year),
X-Rays, Cleanings (2 per year)
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Deductible Per Insured  |
 None |
Benefit Year One |
100% |
Waiting Period |
None |
Benefit Year Two |
100% |
Coinsurance
|
100%
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Benefit Year Three and Each Thereafter |
100% |
Deductible Per Insured |
$50Lifetime |
Waiting Period
|
None
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Class B - Basic Services
Fillings, Endodontics, Oral Surgery,
Simple Extractions, Periodontics
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Class B - Basic Services
Fillings, Endodontics, Oral Surgery,
Simple Extractions, Periodontics
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Deductible Per Insured |
$50/Year* |
Benefit Year One |
35% |
Waiting Period |
6Months |
Benefit Year Two |
50% |
Coinsurance
|
80%
|
Benefit Year Three and Each Thereafter |
65% |
Deductible Per Insured |
$50/Year* |
Waiting Period
|
None
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Class C - Major Services
Crowns, Bridges, Dentures
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Class C - Major Services
Crowns, Bridges, Dentures
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Deductible Per Insured |
$50/Year* |
Benefit Year One |
10% |
Waiting Period |
12Months |
Benefit Year Two |
25% |
Coinsurance
|
50%
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Benefit Year Three and Each Thereafter |
50% |
Deductible Per Insured |
$50/Year* |
Waiting Period
|
None
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Calendar Year Maximum for
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Calendar Year Maximum for
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Classes A, B and C* Combined
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$1000 or
$2000
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Classes A, B and C* Combined
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$1000 or
$2000
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* Class B & C Deductible is combined for each calendar year.
You must choose $1000 or $2000 for a Calendar Year Maximum.
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* Class B & C Deductible is combined for each calendar year.
You must choose $1000 or $2000 for a Calendar Year Maximum.
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