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    LSG Dental

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    res6250
    This dental insurance plan has in-network and out-of-network deductibles of $50 that are waived for preventative services. It covers preventative services at 100% in-network and out-of-network. Basic services such as fillings and oral surgery are covered at 80% in-network and out-of-network, while major services like bridges, dentures and crowns are covered at 50% in-network and out-of-network. The plan has a $1,000 annual maximum benefit for both in-network and out-of-network services, as well as a $1,000 lifetime orthodontic maximum.

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    LSG Dental

    Uploaded by

    res6250
    187 views1 page
    This dental insurance plan has in-network and out-of-network deductibles of $50 that are waived for preventative services. It covers preventative services at 100% in-network and out-of-network. Basic services such as fillings and oral surgery are covered at 80% in-network and out-of-network, while major services like bridges, dentures and crowns are covered at 50% in-network and out-of-network. The plan has a $1,000 annual maximum benefit for both in-network and out-of-network services, as well as a $1,000 lifetime orthodontic maximum.

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    This dental insurance plan has in-network and out-of-network deductibles of $50 that are waived for preventative services. It covers preventative services at 100% in-network and out-of-network. Basic services such as fillings and oral surgery are covered at 80% in-network and out-of-network, while major services like bridges, dentures and crowns are covered at 50% in-network and out-of-network. The plan has a $1,000 annual maximum benefit for both in-network and out-of-network services, as well as a $1,000 lifetime orthodontic maximum.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xls, pdf, or txt
    187 views1 page

    LSG Dental

    Uploaded by

    res6250
    This dental insurance plan has in-network and out-of-network deductibles of $50 that are waived for preventative services. It covers preventative services at 100% in-network and out-of-network. Basic services such as fillings and oral surgery are covered at 80% in-network and out-of-network, while major services like bridges, dentures and crowns are covered at 50% in-network and out-of-network. The plan has a $1,000 annual maximum benefit for both in-network and out-of-network services, as well as a $1,000 lifetime orthodontic maximum.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xls, pdf, or txt
    of 1

    In-Network Deductible - $50 (Waived for Preventative Services)

    Out-of-Network Deductible - $50 (Waived for Preventative Services)

    Services

    Preventative Services: In-Network: 100%


    Emergency Palliative Treatment Out-of-Network: 100%
    Oral Examination - every 6 months
    X-Rays
    Teeth Cleaning - every six months
    Flouride Treatments
    Space Maintainers for Children
    etc.

    Basic Services: In-Network: 80%


    Lab Test Out-of-Network: 80%
    Diagnostic Consultation - 1 per year
    Fillings: Amalgam, Acrylic & Posterior Composites
    Crowns: Stainless Steel
    Repairs of dentures, bridgework, crowns, etc.
    Endodontic Services
    Oral Surgery-Uncomplicated extractions
    General Anesthesia - surgical procedures only
    Injectable Antibiotics - for treatment of a dental condition only

    Major Services In-Network: 50%


    Bridges Installation-fixed and removable Out-of-Network: 50%
    Dentures - Full and Partial
    Crowns: Resin, Metal, Porcelain
    Inlays
    Onlays
    Posts

    Benefit Maximums
    Calendar Year: In-Network: $1,000
    Out-of-Network: $1,000

    Orthodontic Lifetime: In-Network: $1,000


    Out-of-Network: $1,000

    Maximum Rollover: In-Network: $350


    Out-of-Network: $250

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