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AMERITAS DENTAL SUMMARY OF BENEFITS
Columbia County Board of Education |
Effective January 1, 2008 through December 31, 2008
Highlights:
Choose
from three plans (Low, Middle or High)
All
plans allow patient to use any dentist
All
plans include Dental Rewards (maximum rollover feature)
All
plans include Adult and Child Orthodontia (12 month wait period - new hires
only)
All
plans include a $50 deductible on Basic and Major Services
All
plans include a $1,000 annual maximum on Preventive, Basic and
Major Procedures
All
plans include a $1,000 lifetime maximum on orthodontia
Low Plan
|
Sample Procedures
|
|
Allowance |
| 0120 |
Periodic Oral Evaluation (Twice
in a Benefit Period) |
$21.00 |
|
1110 |
Prophylaxis - Adult
(Twice in a Benefit Period) |
$45.00 |
|
0272 |
Bitewings -
two films (Twice in a Benefit Period) |
$19.00 |
|
2140 |
Amalgam restoration - one
surface, primary or permanent |
$30.00 |
|
3310 |
Endodontics - root
canal, anterior |
$185.00 |
|
2792 |
Crown - full cast noble
metal |
$150.00 |
Employee $16.16
Employee & One
Dependent $31.16
Employee & 2
or more Dependents $52.24
Middle Plan
|
Sample Procedures
|
|
Allowance |
| 0120 |
Periodic Oral Evaluation (Twice in a
Benefit Period) |
$23.00 |
| 1110 |
Prophylaxis - Adult
(Twice in a Benefit Period) |
$50.00 |
| 0272 |
Bitewings -
two films (Twice in a Benefit Period) |
$21.00 |
| 2140 |
Amalgam restoration - one
surface, primary or permanent. |
$39.00 |
| 3310 |
Endodontics - root
canal, anterior. |
$241.00 |
| 2792 |
Crown - full cast noble metal |
$200.00 |
Employee $20.84
Employee & One
Dependent $39.80
Employee & 2 or more Dependents $65.56
High Plan
Coinsurance (Plan Pays)
Preventive
Procedures.................................................................................................................................100%
Cleaning,
Exams, Space Maintainers, Fluoride for Children under age 19, X-Rays, Sealants
Basic Procedures............................................................................................................................................80%
Fillings,
Anesthesia, Simple Extractions, Oral Surgery, Root Canals, Gum Disease, Denture
Repair
Major Procedures............................................................................................................................................50%
Crowns, Dentures,
Bridges, Onlays
Employee $36.84
Employee & One
Dependent $74.52
Employee & 2
or more Dependents $120.68
|