| |
In Network |
Out of Network (R&C)* |
|
Calendar Year Deductible |
$50 |
$50 |
|
Deductible Waived for Preventive |
Yes |
No |
|
Coinsurance Amounts: |
|
|
|
Preventive |
100% |
90% |
|
Basic (Oral Surgery classifies as Basic Services) |
80% |
70% |
|
Major (Periodontics & Endodontics classifies as Major Services) |
50% |
50% |
|
Calendar Year Maximum |
$1 ,000 |
$1 ,000 |
|
Family Deductible Limit |
Three (3) times individual deductible |
|
Initial Rate Guarantee |
May 31, 2004 |
|
Employee/Dependent Participation Assumptions |
Standard 100% required for Non-Contributory Plans
75 - 99% required for Contributory Plans |
|
Contributory |
Yes, Employee and Dependants |
|
Benefit Waiting Periods |
Twelve (12) months for Major Services |
* Benefits are paid at resonable and Customary (R&C), less Coinsurance and Deductible.
Additional Plan Options may be available to match prior Plan Coverage. Please inquire with your Sales Representative. |