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This is an outline only to provide a overview of benefits. It does not
constitute the group policy and is not a contract of insurance. This outline
provides essential features of the group benefits provided. All rights with
respect to the benefits of an insured person will be governed solely by the
current group policy Plan Document.
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For specific Plan benefits, limitations and exclusions please see your Summary
Plan Document for further information or call Delta Dental’s Customer Service
Department toll-free at (888) 335-8227.
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| Maximum Annual Benefits |
$1,000
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Calendar Year Deductible
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None
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Coinsurance
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70% of Delta dentist’s fee**
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Benefits
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The Plan pays a wide
variety of eligible expenses. Please see your Summary Plan
Document for further information or call Delta Dental’s
Customer Service Department toll-free at (888) 335-8227.
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Limitations
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The Plan does have
limitations on specific services.
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Exclusions
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The Plan has a
specific list of services that are not covered as eligible
dental expenses.
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**Under this program, Delta pays 70% of
the approved fees for covered diagnostic, preventive, basic,
cast and crown benefits during the first year you are
eligible. This percentage will increase 10% each year (to a
maximum of 100%) for each enrollee, provided that person
visits the dentist at least once during the year. If an
enrollee does not use the program during a calendar year,
the percentage remains at the level reached the previous
year. If an enrollee becomes ineligible for benefits and
later regains eligibility, the percentage will drop back to
70%.
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Please see your Summary Plan Document
(Plan Document) for greater details.
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| Tri-County Schools Insurance Group also offers, by employee
group, additional options in its Dental Program.
The add-on costs are for active employees placed
on the composite, family rate structure. Please see tiered
rate schedule for active employees on a tiered rate schedule or
retirees.
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| From $1,000 Annual Maximum to $1,500 Annual Maximum - $10.00
per employee per month. |
| From $1,000 Annual Maximum to $2,000 Annual Maximum - $15.50
per employee per month. |
| Child Only Orthodontics, 50/50 from $500 to $1,000 lifetime -
$2.00 per employee per month. |
| Adult/Child Orthodontics from $500 to $1,000 lifetime - $3.00
per employee per month. |
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