Dental Planscs3 option2 - Southland Benefit Solutions

1 Preventive ServicesBasic ServicesMajor ServicesOral ExaminationsX-rays - bitewingsX-rays - OtherProphylaxis (Cleanings)Flouride TreatmentsSealantsDiagnostic CastsSpace MaintainersPalliative CareOral ExaminationsX-rays - bitewingsX-rays - OtherProphylaxis (Cleanings)Flouride TreatmentsSealantsDiagnostic CastsSpace MaintainersPalliative Care Oral ExaminationsX-rays - bitewingsX-rays - OtherProphylaxis (Cleanings)Flouride TreatmentsSealantsFillingsProsthodontic RepairsSimple ExtractionsComplex Oral SurgeryAnesthesiaEndodonticsPeriodontics FillingsProsthodontic RepairsSimple ExtractionsComplex Oral SurgeryAnesthesiaEndodonticsDiagnostic CastsSpace MaintainersPalliative CareFillingsProsthodontic RepairsSimple ExtractionsInlays/OnlaysBridgesSingle CrownsDenturesPeriodonticsInlays/OnlaysB ridgesSingle CrownsDenturesInlays/OnlaysBridgesSingle CrownsDenturesComplex Oral SurgeryAnesthesiaPeriodonticsEndodontics Optional ServicesAnnual DeductibleAnnual MaximumWaiting PeriodsDentist RequirementsParticipation

2 RequirementsAdult and Child Orthodontics, Cosmetic Benefits, TMJ Benefits, Maximum Roll Forward reward$0 - $250 per person annually, $75 - $250 lifetime$500 - $3,000 per person Basic or major services 0 - 24 monthsFreedom of choice but save money in networkProvided in proposal80% - 100% MAC50% - 100% MAC0% - 60% MACSAMPLE 1 SAMPLE 2 SAMPLE 3*This sheet reflects examples of Dental plan designs and customizable options available upon Dental2200 Jack Warner Parkway, Suite 150 | Tuscaloosa, AL 35401 | Phone: (205) 343-1250 | Toll Free: 1 (800) 476-3010 |