Schedule of Benefits
Benefits under the plan are divided into four classes:
Class I Benefits cover 100% of diagnostic and preventive services including X-rays.
Class II Benefits cover basic dental services such as oral surgery, minor restorative services, periodontics and endodontics. Class II Benefits are paid at 80% after deductible.
Class III Benefits cover prosthodontics and major restorative services. Benefits are paid at 50% after deductible.
Class IV Benefits cover orthodontics for dependents under age 19. Orthodontics for plan participants age 19 and older may be covered if there is a medical necessity for the orthodontic treatment. Benefits are paid at 50%.
For Class I, Class II and Class III Benefits, the dental plan pays a combined maximum of $2,000 per person per year. For Class IV Benefits, the maximum is $2,000 per person per lifetime.