Schedule of Benefits

(Also see SCHEDULE SUPPLEMENT)

The following Benefits are provided subject to the provisions below.

BENEFITS (MEMBER AND DEPENDENT)

DENTAL EXPENSE BENEFITS

This Plan is intended as an indemnity plan with benefits of a PPO network which will provide savings.

                                                  

ANNUAL DEDUCTIBLE AMOUNT

(For Type B and Type C Expenses Combined

In-Network

Amount

Out-of-Network

Amount
Individual   $25 $25
Family   $75  $75
     
COVERED PERCENTAGE    
Type A Expenses  100%  100%
Type B Expenses  80%  80%
Type C Expenses 50% 50%
Type D Expenses 50% 50%
     
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MAXIMUMS

For Orthodontic Treatment

Aggregate Maximum Benefit

(For All Dental Expense Periods)     

  $1,250

For Other In-Network Covered Dental Expenses

Maximum Benefit

(For One Dental Expense Period)  

$1,000 of Combined In-Network Covered

  Dental Expenses and Out-of-Network

  Covered Dental Expenses

For Other Out-of-Network Covered Dental Expenses

Maximum Benefit (For One Dental Expense Period)            

 

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$1,000 of Combined In-Network Covered Dental Expenses and Out-of-Network Covered Dental Expenses

NOTE(S)

Expenses for orthodontia, including any procedures necessary for such treatment, will be considered Covered Dental Expenses only if the Dependent child has not reached age 19.

Covered Dental Expenses for orthodontia are not included in the Maximum Benefit For One Dental Expense Period.

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.

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WHEN YOU RETIRE

No benefits are provided under This Plan on or after the day you retire.

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