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<br />RETIREE OPTION <br /> <br />OPTION n <br />A. Dental Care Benefits <br />Scheduled amounts are payable up to $2,000 per covered individual per calendar year for preventive <br />and diagnostic care, restorative treatment, root canals, periodontics ($500 lifetime maximum), oral <br />surgery and orthodontia ($1,000 maximum per course of treatment, for adults or children). Some <br />benefits require a 12 month waiting period before benefits are available. <br />Type I Preventive & Diagnostic - Annual Maximum $2,000 <br />a. Oral exams, including prophylaxis: <br />b. Bitewings, per film: <br />c. X-ray, panoramic or cephalometic: <br />d. Sealants/topical fluoride: <br />e. Space maintainers: <br /> <br />PLAN PAYS <br />$48.00 <br />$6.40 <br />$48.00 <br />$13.60 <br />$144.00 <br /> <br />Type 2 Major Restorative - Annual Maximum $2,000/12 month waiting <br />period applies <br />a. Crowns, bridges and dentures: <br />b. Pre-fabricated crowns: <br />c. Crown build-up procedures: <br /> <br />$240.00 <br />$80.00 <br />$64.00 <br /> <br />Type 3 Minor Restorative - Annual Maximum $2,000 <br />a. Fillings: <br />b. Crown, bridge and denture repair: <br />c. Relining or rebasing dentures: <br /> <br />$56.00 <br />$32.00 <br />- $80.00 <br /> <br />Type 4 Endodontics - Annual Maximum $2,000 <br />a. Root canals, apicoectomies: <br />b. Root amputation: <br />c. Therapeutic pulpotomy, retrograde, fillings, apexification and <br />Hemisection: <br /> <br />$256.00 <br />$128.00 <br />$64.00 <br /> <br />Type 5 Periodontics - Lifetime Maximum $500/12 month waiting period <br />applies <br />a. Tissue grafts or bone surgery: <br />b. Gingivectomy (per quadrant), periodontal scaling, periodontal splinting <br />and root planning: <br />c. Gingival curettage (per quadrant): <br />d. Gingivectomy (per tooth): <br /> <br />$128.00 <br />$80.00 <br /> <br />$48.00 <br />$32.00 <br /> <br />Type 6 Oral Surgery - Annual Maximum 52,000/12 month waiting <br />period applies <br />a. Surgeries Levell (removal of exostosis): <br />b. Surgeries Level 2 (removal of impacted tooth): <br />c. Surgeries Level 3 (simple extraction): <br /> <br />$160.00 <br />$88.00 <br />$48.00 <br /> <br />Type 7 Anesthesia - Annual Maximum 52,000/12 month waiting period <br />applies <br />a. Intravenous sedation: <br />b. General anesthesia, first half-hour and each additional quarter-hour: <br /> <br />$96.00 <br />$96.00 <br /> <br />Type 8 Orthodontia - Annual Maximum 52,000/12 month waiting period <br />applies <br />a. Adult or Child - per course of treatment <br /> <br />$500.00 <br /> <br />Types through 7 subject to annual maximum of $1 ,000 <br />Types 2, 5, 6a, 7 and 8 are subject to 12-month waiting period <br /> <br />RATES <br /> <br />Retiree Only 520.00 <br />Retiree & Spouse $40.00 <br />Retiree & Child{ren) $55.00 <br />Family $75.00 <br /> <br />Dental Only Option <br /> <br />B. <br /> <br />No Dental <br /> <br />C:\Documcnts and Settings\ganderson\Local Settìngs\TCß1X>rary Internet Files\OLK5\EarlyRet.doc <br /> <br />-- <br /> <br />--- <br />