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Ameritas/The PrincipalPPO DENTAL NETWORK YOU …

Ameritas/The PrincipalPPO DENTAL NETWORK The Business Council of New York State, Inc. • 026-50004 BENEFITS PROVIDED UNDER THIS POLICY AND ANY LIMITATIONS THAT MAY APPLY TO YOU OR YOUR …

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TABLE OF DENTAL PROCEDURES PLEASE READ …

www.employeebenefitservice.com

9232 TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are payable under this section is based upon the

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TABLE OF DENTAL PROCEDURES PLEASE READ …

www.employeebenefitservice.com

TYPE 1 PROCEDURES • Coverage is limited to 2 of any of these procedures per 1 benefit period. • D1201, D1205, D4910, also contribute(s) to this limitation.

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FREQUENCIES AND PROVISIONS. - Employee Benefit Service

www.employeebenefitservice.com

D2410 Gold foil - one surface. D2420 Gold foil - two surfaces. D2430 Gold foil - three surfaces. COMPOSITE RESTORATIONS: D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394 ... D2931 Prefabricated stainless steel crown - permanent tooth. D2932 Prefabricated resin crown.

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MedSolutions is Aetna’s third-party vendor for Southern New Jersey. Southern New Jersey includes Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer and Salem counties.

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