Plan Features

Family Coverage

For spouse and dependent children, birth through 18, or through 22 if the child is a full time student, dependent on the member for support.

Policy Changes

To your coverage, including adding a dependent or changing benefits, may ONLY be made on your policy anniversary date.

Premium Payment Only

From an Authorized Checking or Savings Account, Automatic Bank Draft arrangement or by MasterCard, VISA, or Discover credit/debit cards will be accepted.

Silver Plan	1st Year	2nd Year	Thereafter
Type I - Preventative/Diagnostic Deductible - Benefit Year Insurance Company Pays	Initial 30 Day Waiting Period -0- 50%	-0- 50%	-0- 50%
Type II - Basic Restorative Deductible - Benefit Year Insurance Company Pays	30 Day Waiting Period $50.00 * 50%	$50.00 50%	$50.00 50%
Type III - Major Restorative Deductible Insurance Company Pays	365 Day Waiting Period Not Covered	$50.00 50%	$50.00 50%
Maximum Benefit Year Type I, II and III	$1,000.00	$1,000.00	$1,000.00
Type IV - Orthodontia Benefits Lifetime Deductible Insurance Company Pays Ortho Lifetime Benefit Limit	Not Covered	Not Covered	$50.00 Lifetime 50% $1,000.00
Bronze Plan	1st Year	2nd Year	Thereafter
Type I - Preventative/Diagnostic Deductible - Benefit Year Insurance Company Pays	Initial 30 Day Waiting Period $35.00 ** 80%	$35.00 80%	$35.00 80%
Type II - Basic Restorative Deductible - Benefit Year Insurance Company Pays	180 Day Waiting Period $35.00 60%	$35.00 60%	$35.00 60%
Type III - Major Restorative Deductible Insurance Company Pays	Not Covered	Not Covered	Not Covered
Maximum Benefit Year Type I, II and III	$750.00	$750.00	$750.00
Type IV - Orthodontia Benefits Lifetime Deductible Insurance Company Pays Ortho Lifetime Benefit Limit	Not Covered	Not Covered	Not Covered

Type I - Preventative/Diagnostic (Fluoride Treatments, X-Rays, Cleaning, Periodic Exams)
Type II - Basic Restorative (Extractions, Fillings, Oral Surgery)
Type III -Major Restorative (Root Canals, Bridges, Crowns, Dentures, Partials, Periodontics)

*Silver Plan contract year deductible may be satisfied in Type II or III services.

**Bronze Plan contract year deductible may be satisfied in Type I or II services.

Benefits are based upon the usual and customary fees charged in the area where service is rendered.
Benefit Year maximums are calculated for each Certificate Year from Certificate Effective Date.