Voluntary Standard Dental Plan
NO WAITING PERIODS
- Lifetime Deductibles
- 24 hour access to your benefit information at www.healthedgeonline.com
| Standard1 | Benefits | |
| Calendar Year Maximum | $1,000 | |
| Preventative Services Lifetime Deductible $50 |
100% | Exams – 2 per calendar year; Cleaning – 2 per calendar year; Bitewing X-rays–1 per calendar yr; Emergency Palliative Treatment; Fluoride – 1 per calendar year to age 16 |
| Basic Services (includes Endodontics) Lifetime Deductible $50 |
80% | Simple Extractions; Fillings; Consultation; Diagnostic X-rays – 1 every 3 yrs; Endodontics (Root Canal); Space Maintainers – to age 14 |
| Major Services Lifetime Deductible $50 |
50% Includes Periodontics |
Oral Surgery, Crowns, Dentures, Bridges, Inlays, Onlays, Nightguards |
- Prior extractions not covered unless it includes replacement of a natural tooth lost or extracted while covered under this plan. Limitation ends after covered under this policy for 36 consecutive months.
- Unmarried dependent children are covered from age 19 until their 23rd birthday, if enrolled as full-time students
- Prosthetic replacement – one time every 5 years.
- One Lifetime Deductible applies per category of service for a total of three Lifetime Deductibles per individual enrolled on the plan.
THIS FORM IS A SUMMARY OF PLAN BENEFITS ONLY –
REFER TO BENEFIT CERTIFICATE FOR COMPLETE BENEFIT DETAILS
INCLUDING LIMITATIONS AND EXCLUSIONS.
HealthEdge Administrators is a wholly owned subsidiary of the Foundation for Medical Care of Kern and Santa Barbara Counties. Established in 1959, the Foundation represents one of the largest PPO Networks in California and Administers Self-Funded Medical and Dental Plans for Employers, Counties and Government Entities. HealthEdge Administrators provides service within the state of California.
HealthEdge Administrators is not affiliated with Healthedge Software, Inc. to visit Healthedge Software’s website: www.healthedge.com
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