SUMMARY OF THE MILA NATIONAL HEALTH PLAN: DENTAL BENEFITS

BENEFIT PLAN	FOR MEMBERS PARTICIPATING IN:
Who Participates
Active Members	Premier, Basic and Core Plans
Retired Members	Premier, Basic and MediCare Wrap-Around Plans
Retired Members	Medicare Advantage Plan if qualified for Part B premium reimbursement
FEATURES	MEMBER BENEFITS & COST
Calendar Year Deductible Expenses
Applies to the following expenses	Applies only to Basic and Major Expenses
Individual Deductible	$25 per calendar year, waived for preventive
Family Deductible Limit	No more than $75 per calendar year
Coinsurance Dental Expense Payable by Participant
Preventive Dental Treatment	0% coinsurance (Plan pays 100%)
Basic Dental Treatment	15% coinsurance after deductible (Plan pays 85%)
Major Dental Treatment	15% coinsurance after deductible (Plan pays 85%)
Orthodontic Dental Treatment	15% coinsurance after deductible (Plan pays 85%)
Maximum Benefit Payable by Plan
Payable for preventive, basic and major dental treatment incurred by each person during each calendar year	$2,500 per person
Payable for orthodontic dental treatment incurred by a child during that child’s lifetime	$1,500 per person
Benefits payable Out-of-Network will be paid based on a charge which would have been eligible if it had been rendered by a Network dentist operating in the Network. Any additional charge presented by that Out-of-Network dentist will be the Member’s responsibility.

The following is important information which every MILA Member covered under the MILA Dental Plan should keep in mind when accessing dental service. This information will help you obtain the highest level of benefits from the MILA Dental Plan while ensuring that you obtain the care you require.