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CONNECTION Dental Plus® covered services, deductibles, limits, waiting periods and premiums.
| 2009 Plan Year |
CONNECTION DentalPlus |
| Benefit Schedule |
| Covered Services |
Calendar Year Deductible |
Waiting Period |
Provider Participation |
Benefit |
|
|
|
|
|
Class A
Specified diagnostic & preventive
|
$0 |
None |
In-network
Out-of-network |
100%
80% |
|
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|
|
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Class B
Other diagnostic, preventive, restorative & specified oral surgery
|
$50 |
None |
In-network
Out-of-network |
80%
70% |
|
|
|
|
|
Class C
Endodontics, periodontics, prosthodontics & crowns, inlays, onlays
|
$100 |
12-month |
In-network
out-of-network |
50%
40% |
|
|
|
|
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Class D
Orthodontics - comprehensive case (ages 6-17)
|
$0 |
24-month |
In-network
Out-of-network |
$50 per month
$25 per month |
|
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Deductibles
- Calendar Year Deductibles apply separately to Class B and Class C Covered Services. The Class B Deductible does not apply to or reduce the Class C Deductible.
- Deductibles apply separately to each Covered Person.
Maximum Limits
- Class A, Class B and Class C Covered Services have a combined Calendar Year Maximum Benefit Limit per Covered Person of $1,200.
- Class D Covered Services have a Calendar Year Maximum Benefit Limit of $600 per Covered Child for treatment by a Participating Provider or $300 for treatment by a Non-participating provider and a Lifetime Maximum Benefit Limit of $1,200 per Covered Child toward treatment by a Participating Provider or $600 for treatment by a Non-participating Provider.
Waiting Periods
- Waiting Periods apply separately to each Covered Person. If an Eligible Dependent's Effective Date of Coverage is later than the Member's Effective Date of Coverage, the Waiting Period for the Eligible Dependent begins on the Effective Date of Coverage for the Eligible Dependent.
- Coverage for Class C Covered Services begins 12 months after the date the Member or Eligible Dependent is first covered under The Dental Plan.
- Coverage for Class D Covered Services begins 24 months after the date the Covered Child is first covered under The Dental Plan.
Benefit Percentages
- Benefit Percentages apply separately to each Covered Person. If an Eligible Dependent's Effective Date of Coverage is later than the Member's Effective Date of Coverage, the Benefit Percentages for the Eligible Dependent begin on the Effective Date of Coverage for the Eligible Dependent.
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