IVSJPA: Dental Benefits Summary
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BENEFIT MAXIMUMS Calendar Year Maximum |
$2000 |
| Benefits for each Covered Person will not exceed the maximums shown above. Orthodontia benefits do not apply to the Calendar Year Maximum. The Orthodontia Maximum applies to all periods a individual is covered under the Plan. Benefits for Eligible Dental Expenses that are related to treatment of TMJ (i.e., disorders of the temporomandibular joint) are subject to both the Calendar Year Maximum and the TMJ Lifetime Maximum. |
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ANNUAL DEDUCTIBLES Individual Deductible |
$25 |
Network and Non-network providers
The Plan Sponsor has contracted with “Networks” of dental providers. Network providers have agreed to provide dental services at negotiated rates. Lists or directories of the Network providers will be given to Plan participants without charge.
When obtaining dental care services in the United States, a Covered Person has a choice of using a provider who is participating in the First Dental Health Network (FDH) or any other Covered Provider of his choice (a Non-Network provider). For in-Mexico services, a First Dental Health (AMEXUS) Network provider or a participating dental laboratory must be used.
When a Covered Person uses a Network provider his out-of-pocket costs may be reduced because he will not be billed for expenses in excess of “Usual, Customary and Reasonable.” The Schedule of Dental Benefits (below) may also include other benefit incentives to encourage Covered Persons to use Network providers whenever possible.
Schedule of Dental Benefits
| ELIGIBLE DENTAL EXPENSES |
FDH Network |
Non-Network |
AMEXUS |
|
| Diagnostic & Preventive Services |
100%† |
80%† |
100%† |
|
| Diagnostic & Preventive Services include the following, some of which are limited by age or frequency as shown below. See the Eligible Dental Expenses section for further detail:
· Biopsy / pathology |
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| Basic Services |
70% – 100%†† |
80% |
70% – 100%†† |
|
| Basic Services include the following. See the Eligible Dental Expenses section for further detail:
· Anesthesia |
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| ELIGIBLE DENTAL EXPENSES |
FDH Network |
Non-Network |
AMEXUS Network |
||
| Major Services |
50% |
40% |
50% |
||
| Major Services include the following. See the Eligible Dental Expenses section for further detail:
· Crowns |
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| Orthodontia |
50% to |
50% to |
50% to |
||
| Orthodontia benefits are limited to a maximum 24-month treatment program. | |||||
† Annual Deductible does not apply.
†† The 70% benefit will apply to benefits provided during a person’s first Calendar Year (or partial year) of coverage. The percentage increases by 10% each consecutive year a dentist is visited to a maximum benefit of 100%. If a dentist is not visited during a year, the percentage remains at the percentage level reached in the prior year. If coverage is terminated and later resumed, benefits restart at the 70% benefit level.
|
BENEFIT MAXIMUMS Calendar Year Maximum |
$1250 |
|
Benefits for each Covered Person will not exceed the maximums shown above. Benefits for Eligible Dental Expenses that are related to treatment of TMJ (i.e., disorders of the temporomandibular joint) are subject to both the Calendar Year Maximum and the TMJ Lifetime Maximum. |
|
|
ANNUAL DEDUCTIBLES Individual Deductible |
$50 |
Network and Non-network providers
The Plan Sponsor has contracted with “Networks” of dental providers. Network providers have agreed to provide dental services at negotiated rates. Lists or directories of the Network providers will be given to Plan participants without charge.
When obtaining dental care services in the United States, a Covered Person has a choice of using a provider who is participating in the First Dental Health Network (FDH) or any other Covered Provider of his choice (a Non-Network provider). For in-Mexico services, a First Dental Health (AMEXUS) Network provider or a participating dental laboratory must be used.
When a Covered Person uses a Network provider his out-of-pocket costs may be reduced because he will not be billed for expenses in excess of “Usual, Customary and Reasonable.” The Schedule of Dental Benefits (below) may also include other benefit incentives to encourage Covered Persons to use Network providers whenever possible.
Schedule of Dental Benefits
| ELIGIBLE DENTAL EXPENSES |
FDH Network |
Non-Network |
AMEXUS Network |
|||
| Diagnostic & Preventive Services |
100%† |
80% |
100%† |
|||
| Diagnostic & Preventive Services include the following, some of which are limited by age or frequency as shown below. See the Eligible Dental Expenses section for further detail:
· Biopsy / pathology |
||||||
| Basic Services |
80% |
70% |
80% |
|||
| Basic Services include the following. See the Eligible Dental Expenses section for further detail:
· Anesthesia |
||||||
| ELIGIBLE DENTAL EXPENSES |
FDH Network |
Non-Network |
AMEXUS Network |
| Major Services |
60% |
50% |
60% |
| Major Services include the following. See the Eligible Dental Expenses section for further detail:
· Crowns |
|||
| Implants
Orthodontia |
Not Covered Not Covered |
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† Annual Deductible does not apply.
†† The 70% benefit will apply to benefits provided during a person’s first Calendar Year (or partial year) of coverage. The percentage increases by 10% each consecutive year a dentist is visited to a maximum benefit of 100%. If a dentist is not visited during a year, the percentage remains at the percentage level reached in the prior year. If coverage is terminated and later resumed, benefits restart at the 70% benefit level.
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