Transcription of Custom DPPO 1 Dental Plan Exclusively for …
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Custom DPPO 1 Dental Plan Exclusively for …
Custom DPPO 1 Dental PPO summary of Benefits Effective4/1/2017 NETWORKNETWORKOUT-OF-NETWORKI ndividual Annual Calendar Year Deductible$50$50$0 $0 Family Annual Calendar Year Deductible$150 $150 $0 $0 No (In Network)No (Out-of-Network)YesNo COVERED SERVICESNETWORK PLAN PAYS*OUT-OF-NETWORK PLAN PAYS**Periodic Oral Evaluation100%100%Routine Radiographs100%100%Non-Routine - Complete Series Radiographs100%100%Prophylaxis (Cleanings)100%100%Fluoride Treatment 100%100%Sealants100%100%Space Maintainers100%100%Palliative Treatment100%100%Restorations (Amalgam or Composite)80%80%Simple Extractions80%80%Oral Surgery (includes surgical extractions)50%50%Endodontics50%50%Anest hetics80%80%Adjunctive Services80%80% MAJOR SERVICES Inlays/Onlays/Crowns50%50%Dentures and other Removable Prosthetics50%50%Fixed Partial Dentures (Bridges)50%50% ORTHODONTIC SERVICES Underwriting Exhibit For Agent Use Only and/or Not For Use with General PublicOffered and Underwritten by Solstice Health Insurance CompanyThe above summary of Benefits is for informational purposes only and is not an offer of coverage.
Custom DPPO 1 Dental PPO Summary of Benefits Effective 4/1/2017 NETWORK NETWORK OUT-OF-NETWORK Individual Annual Calendar Year Deductible $50 $50 $0 $0
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