(Also see SCHEDULE SUPPLEMENT)
The following Benefits are provided subject to the provisions below.
BENEFITS (MEMBER AND DEPENDENT) AMOUNT
DENTAL EXPENSE BENEFITS
In-Network
Amount
Out-of-Network
Amount
$50
$50
$150
$150
Applies to
Type B and
C Services
Combined
Applies to
Type B and
C Services
Combined
100%
80%
80%
60%
50%
30%
MAXIMUMS
In-Network Maximum Benefit - (For One Dental Expense Period) $750 of Combined In-Network Covered Dental Expenses and Out-of-Network Covered Dental Expenses
Out-of-Network Maximum Benefit - (For One Dental Expense Period) $750 of Combined In-Network Covered Dental Expenses and Out-of-Network Covered Dental Expenses.
NOTE(S)
If a dental bill is expected to be $300 or more, see DENTAL EXPENSE BENEFITS, section F. PRE-DETERMINATION OF BENEFITS.
COORDINATION OF BENEFITS
The Dental Expense Benefits are subject to the provisions of the form entitled COORDINATION OF BENEFITS.
WHEN YOU RETIRE
No benefits are provided under This Plan on or after the day you retire.