Dental Benefit Payable Under the Plan
The following benefits will be payable for covered services under the Plan. The eligible charge will be limited to the lesser of (1) the actual charge made by the dentist for the service or supply and (2) the eligible contracted charge. The eligible contracted charge will be based on whether the service had been performed or the supply had been provided by a contracted network dentist who was qualified to perform the eligible work in the geographic area in which it was performed or supplied.
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Calendar Year Deductible. A calendar year deductible shall be paid by the participant for all covered Basic Restorative Care and Major Restorative Care Services before any such benefits will be payable. The deductible will not apply to Diagnostic and Preventive Care and Orthodontic Care. The deductible is $25 per individual per calendar year. No more than an aggregate family limit of $75 in deductible expenses will be charged to the family during a calendar year, regardless of the number of family members who incur such expenses. It is not necessary that any individual satisfy an individual deductible if the family first incurs the family limit of deductible expenses.
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Diagnostic and Preventive Care Coinsurance. Expenses incurred for Diagnostic and Preventive Care shall be reimbursed at 100% but no more than the Plan’s maximum benefit will be paid for expenses incurred during the calendar year.
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Basic Restorative and Major Restorative Care Coinsurance. Expenses incurred for Basic Restorative Care and Major Restorative Care shall be reimbursed at 85% but no more than the Plan’s maximum benefit will be paid for expenses incurred during the calendar year.
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Orthodontic Care Coinsurance. Expenses incurred for Orthodontic Care shall be reimbursed at 85% but no more than the Plan’s maximum lifetime benefit will be paid for expenses incurred during the individual’s lifetime.
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Maximum Dental Plan Benefit. The Plan shall pay no more than $2,500 in reimbursement for Preventive, Basic and Major dental expenses incurred by an individual during a calendar year. In addition, the Plan shall pay no more than $1,500 in reimbursement for Orthodontic dental expenses that are incurred by an individual during that individual’s lifetime.
