1.)
Benefits paid under the Indemnity UCR Plan are paid at the Usual, Customary
and Reasonable (UCR) charges in the applicable area. |
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| 2.)
Benefits paid under the PPO UCR plan are based on the applicable Preferred
Provider Organization (PPO) contract procedure allowances for In-Network
claims, and at the Usual, Customary and Reasonable (UCR) charges in the
applicable area for Out-of-Network claims. |
| |
3.)
Benefits paid under the PPO schedule Plan are based on the applicable
Preferred Provider Organization (PPO) contract procedure allowances
for both In-Network and Out-of-Network claims. |
|
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4.) The Calendar Year Deductible is waived for Type I , Preventative and
Diagnostic, Services. |
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| 5.)
Only one treatment per tooth (permanent posterior only) or quadrant during
a 36 month consecutive month period. |
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| 6.)
For Groups with 2 to 4 covered employees and all Voluntary Plans, Endodontics,
and Periodontics are covered under Type III, Major, Services only. |
| |
7.)
All Type III, Major, Type IV, Orthodontia, Services are subject to a
12 month waiting period. |
