• Maximums:
  • Dental maximum per plan year $1,250 per person
  • Orthodontics lifetime maximum $1,500 per person
  • Occlusal Guards lifetime maximum $500 per person

• Deductibles: $50 per individual/$100 per family per plan year

• Eligible expenses:
  • 100% of Usual, customary and reasonable (UCR) for
    preventive services - (deductible does not apply)
    includes oral examination, prophylaxis (cleaning),
    and bite-wing x-rays (not more than twice every year)
   
  • 80% of UCR - basic dental services (other x-rays, fillings, root canals)
   
  • 50% of UCR- major dental services (crowns, inlays)

The dental portion of your coverage has no network of providers. You may obtain services from any dentist (or hygienist) licensed to practice in the state where services are rendered.

Payment of Dental Services
If your provider is willing to submit your claim to the insurance on your behalf, they may send their statement directly to the Medical/Dental Claims Administrator identified on your ID card. Their statement should include the name and Health Insurance ID number of the Plan Member (resident/fellow) and the name of the patient. Payment will be made directly to your provider and you will receive a copy of the payment notice/EOB (Explanation of Benefits). If your provider requires payment at time of service, or they do not bill insurance for their patients or this Plan, they should give you an itemized statement to send to the Claims Administrator. If you pay the provider, please indicate clearly on the statement that reimbursement should be made payable to the plan member.