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Group Dental Plan:    #2

Annual Maximum:    $3,000 per calendar year

     $2,500 Orthodontic Lifetime Maximum (excludes treatment started prior to 01/01/18)

Deductible:        None

Coverage:        Incentive 70-80-90-100% Preventive and Basic

   Each annual visit increases 10%, each missed year decreases 10% 

   50%    Prosthetics, Implants, Orthodontics 

Waiting Period:    No  

Dependents:        To age 26, no restrictions

Benefit Limitations:    

• Exams                     2 in a calendar year

• Prophylaxis or Perio maintenance    2 in a calendar year

• Fluoride                 2 in a calendar year 

• Bitewing Xrays             2 in a calendar year 

• Full Mouth                 1 in 5 years     

• Panorex                 1 in 5 years

• Sealants                 1 in 3 years to age 16

  • (1st and 2nd permanent molars)

• Scaling and Root Planing        1 in 2 years

  •  (All four quads can be done on the same day)

Limitations:        5 year replacement on Crowns and Prosthetics

Exclusions:        TMJ        Night Guards

Exceptional Coverage:    Posterior Composites

Claim Filing Limit:    6 months

Preauthorization:    Requested over $500

Alternate Benefit Clause:  Based on the least expensive treatment that is professionally accepted.

Coordination of Benefits:    Standard 

Claims Address:      Stanislaus Dental Foundation, PO Box 576007, Modesto, CA 95357

          Phone # 209-527-2430     Fax # 209-524-8773

Payer ID:        IN202