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Other
Benefit Summaries:
MEDICAL
DENTAL
LIFE
LTD
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Dental Plan
- EBMS Administrators
January 1, 2004 -
December 31, 2004 |
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Information provided is in summary
format. Any difference between the summary provided and
actual contract will be settled in favor of the contract.
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Deductible |
$50 per Person/$150 per Family
|
|
Waived
for Preventive |
Yes
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Preventive
- Includes Exams, Fluoride, Space Maintainers,
Prophy, Perio Prophy, Bitewings, Full Mouth Xrays,
Sealants
|
100%
|
|
Basic
- Includes Fillings, Extractions,
Periodontics, Endodontics, Emergency
Care, Oral Surgery, Recementing of
Bridges/ Inlays/Onlays/Crowns,
Services for TMJ, Repairs to
Bridges, Antibiotics |
80%
|
|
Major
- Includes Inlays, Onlays, Crowns,
Bridges, Dentures, Relining of
Dentures, Crown Buildup on nonvital
teeth. |
50%
|
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Annual
Maximum |
$1,000
|
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Dependent
Age Limit |
Up to age 19; 23 if full-time student |
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Pre-Estimate
Recommended For: |
Procedures
over $300
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Orthodontia |
Not Covered
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Please refer to your dental
booklet for specific limitations on Preventive, Basic, and Major services.
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