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Martin County Board of County Commissioners I Employee Benefit Highlights 12021 Dental Insurance Florida Combined Life BlueDental Choice Plus PPO Plan The County offers dental insurance through Florida Combined Life,a subsidiary Out-of-Network Benefits of Florida Blue,to benefit-eligible employees. A brief summary of benefits is provided on the following page.For more detailed information about the Out-of-network benefits are used when member receives services by a non- dental plan,please refer to the carrier's summary plan document or contact participating Florida Combined Life BlueDental Choice Plus PPO provider. Florida Combined Life's customer service. Florida Combined Life reimburses out-of-network services based on what it determines as the Usual,Customary and Reasonable(UCR).The UCR is defined Dental Plan Premium as the most common charge for a particular dental procedure performed in a specific geographic area. If services are received from an out-of-network The County offers all benefit-eligible employees,medical and dental coverage dentist,the member may be responsible for balance billing.Balance billing is as a"bundled"package.However,employees can elect to opt-out of the dental the difference between Florida Combined Life's UCR and the amount charged plan and remain on the medical plan only.In order to opt-out of the dental by the out-of-network dental provider.Balance billing is in addition to any plan,employee will be required to waive this election in Bentek. applicable plan deductible or coinsurance responsibility. Please Note:if a participant elects to opt-out of the MCBOCC's sponsored dental Calendar Year Deductible plan payroll deduction will remain the same. There will not be a decreasein premium. The BlueDental Choice Plus PPO plan requires a$50 individual or a$100 Family deductible to be met for in-network or out-of-network services before most In-Network Benefits benefits will begin.The deductible is waived for preventive services. The BlueDental Choice Plus PPO plan provides benefits for services received Calendar Year Benefit Maximum from in-network and out-of-network providers.It is also an open-access plan which allows for services to be received from any dental provider without The maximum benefit(coinsurance)the BlueDental Choice Plus PPO.plan will having to select a Primary Dental Provider(PDP) or obtain a referral to a pay for each covered member is$1,000 for in-network and out-of-network specialist.The network of participating dental providers the plan utilizes is services combined. All services, including preventive services, accumulate the Florida Combined Life BlueDental Choice Plus network.These participating towards the benefit maximum.Once the plan's benefit maximum is met,the dental providers have contractually agreed to accept Florida Combined Life's member will be responsible for future charges until next calendar year. contracted fee or"allowed amount:'This fee is the maximum amount a Florida Combined Life dental provider can charge a member fora service.The member Florida Combined Life is responsible for a Calendar Year Deductible(CYD)and then coinsurance based Customer Service:(888)223-4892 1 www.floridabluedental.com on the plan's charge limitations. Group Number:247L66 89 7 ©2016,Gehring Group,Inc.,All Rights Reserved