Welfare Summary Plan Description

9.2 CALENDAR YEAR DEDUCTIBLE AND MAXIMUM BENEFIT PAYABLE

The deductible is the amount of Covered Dental Expenses which must be incurred during each calendar year before dental care benefits are payable. The deductible for each Participant is the first $75 of Covered Dental Expenses incurred per calendar year. The deductible does not apply to Orthodontic services as well as diagnostic and preventive services.

  • Dental care benefits (Class I, Class II, and Class III) are limited to a maximum benefit payable of $2,000 per Participant or beneficiary, for ages 19 and older, during each calendar year. For those eligible who are under age 19, the $2,000 maximum does not apply. Any dental treatment is subject to exclusion from Plan benefits if determined not to satisfy the Plan's UCR and/or dental necessity requirements.
  • Orthodontia benefits are available only through age 18 (under the age of 19), and are limited to a lifetime maximum benefit payable of $1,200 per Dependent child.