Dental Plan Benefit Summary
| Service | Network |
|---|---|
| Coverage A - No Deductible | You Pay |
| Examinations Prophylaxes (teeth cleaning) Fluoride Bitewing Radiographs (x-rays) Sealants |
0% |
| Coverage B - $50 per person deductible* | You Pay |
| Emergency Palliative Treatment Space Maintainers All Other Radiographs (x-rays) Minor Restorative Services (fillings) Simple Extractions |
20% |
| Coverage C - $50 per person deductible* | You Pay |
| Prosthetic Repair All Other Oral Surgery Periodontics Endodontics Prosthodontics (bridges, dentures, partials) Major Restorative Services (crowns, inlays, onlays) 12 month waiting period for these services. The waiting period is waived with proof of 12 month continuous dental coverage for major services immediately prior to effective date of coverage in MCHCP’s dental plan. |
50% |
| *Coinsurance amounts apply after the $50 individual deductible is met under either Coverage B or C or combined. | |
| Coverage is limited to $1,000 per person per calendar year. 2009 Plan Year: Dental exams, x-rays, cleanings and fluoride trearment do not apply to the $1,000 individual plan maximum. |
|