JC - 2024 Employee Benefits Guide - (FINAL 11.28.2023) SPR

DENTAL PPO PLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible (calendar year)

Individual: $50 Family: $150

Individual:

$50

Family:

$150

Annual Benefit Maximum

$1,000

$1,000

Diagnostic & Preventive Services Prophylaxis (Cleanings); Oral Examinations; Topical Fluoride; X-rays; Bitewing; Sealants (up to age 16); Space Maintainers Basic Services Restorative Amalgams; Restorative Composites; Denture Repair; Simple & Complex Extractions; Anesthesia Major Services Onlays; Crowns; Crown Repair; Endodontics (non-surgical & surgical); Periodontics (non-surgical & surgical); Prosthodontics (fixed bridge; removable complete/partial dentures)

100% Deductible waived

100% Deductible waived

80% After deductible

80% After deductible

50% After deductible

50% After deductible

Dependent Age Limit

To age 25 (coverage terminates date dependent turns 25)

For additional information, please refer to your detailed plan summary. In the event of a discrepancy, the carrier Plan Document shall prevail.

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