Benefit Schedule for Perfect Smile
This plan is an indemnity plan which allows you complete freedom of dentist choice. Reimbursements are based on a percentage of the Usual, Customary and Reasonable Fees (UCR) charged by dentists in your area. It is your dentist’s responsibility to check the benefits provided by this policy and inform you of any amounts that you are responsible for.
|Fee Schedule Summary*|
|* The Policy and Fee Schedule has exclusions and limitations. Please refer to the Exclusions and Limitations section in the Plan Info tab of this site for a listing. Products and services are not available in all states.|
|Preventive Dental Benefits||Routine exams, teeth cleanings, topical fluoride (children up to age 16).
No waiting period.
|Plan Pays 100%|
|Basic Dental Benefits||Fillings, X-rays, simple extractions.
6 month waiting period.
|Plan Pays 80%|
|Major Dental Benefits||Oral surgery (surgical extractions & impactions), endodontics, periodontics, crowns, bridges, dentures.
18 month waiting period.
|Plan Pays 50%|
|Dental Deductible||Per calendar year, per insured person, combined for Preventive, Basic, & Major Services.||$50|
|Maximum Dental Benefits||Per calendar year, per insured person.||$1000|