Dental Expense Benefits. Maximum benefit for: • Types I, II and III Services combined • Type IV Services $1,500 per calendar year $1,000 per Lifetime Calendar year deductible amount • Type I Services • Types II, III and IV Services combined None $25 per Covered Person $50 per Family Benefit percentage for: • Type I Services (Diagnostic & preventive) • Type II Services (Basic and oral surgery) • Type III Services (Major) • Type IV Services (Orthodontia) 100% 80% 80% 60% MEDICAL BENEFITS SCHEDULE – PLAN A NETWORK PROVIDERS NON-NETWORK PROVIDERS Note: The maximums listed below are the total for Network and Non-Network expenses. For example, if a maximum of 60 days is listed twice under a service, the Calendar Year maximum is 60 days total which may be split between Network and Non-Network providers. DEDUCTIBLE, PER CALENDAR YEAR Per Covered Person $100 $200 Per Family Unit $200 $400 The Network Deductible amounts will be combined with the Non-Network Deductible amounts. The Calendar Year deductible is waived for the following Covered Charges: - Preventive Care - Emergency Room services - Network services with a per-visit Copayment - Second Surgical Opinion when recommended by the Case Manager COPAYMENTS Physician visits $15 $25 Urgent Care Facility $25 $35 Emergency Room services $50 $50 The Emergency room copayment is waived if the patient is admitted to the Hospital on an emergency basis. The utilization review administrator must be notified at (000) 000-0000 within 48 hours (or 2 business days) of the admission, even if the patient is discharged within 48 hours (or 2 business days) of the admission. MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR Per Covered Person $400 $1,000 Per Family Unit $1,000 $2,000 The Network Out-of-Pocket amounts will be combined with the Non-Network Out-of-Pocket amounts. The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum: Deductible(s) Non-Precertification penalties Copayments Amounts over Usual and Reasonable Charges Charges for Prescription Drugs obtained under the Prescription Drug Benefit section of this Plan COVERED CHARGES Inpatient Hospital Services Room, Board, and Miscellaneous Expenses 90% after deductible 70% after deductible Intensive Care Unit 90% after deductible 70% after deductible Outpat...
Dental Expense Benefits. The Company agrees to provide a Dental Care Plan for the hourly employees. New Employees will not be eligible for coverage under the Dental Plan until they have completed one (1) year of service. Payments will be two (2) years behind the current ODA schedule (for example, benefits paid in 2018 will be at the 2016 fee schedule; in 2019, benefits will be according to the 2017 fee schedule; in 2020, benefits will be according to the 2018 fee schedule). Employees will contribute as follows: Single coverage: $1.00 per week Family coverage: $1.50 per week.
