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Martin County Board of County Commissioners I Employee Benefit Highlights I 20210 <br /> Florida Combined Life BlueDental Choice PPO Plus Plan At-A-Glance <br /> Network BlueDental Choice Plus <br /> Calendar Year Deductible(CYD) In-Network Out-of-Network* <br /> Per Member J $50 <br /> Per Family –V $100 <br /> Locate a Provider <br /> --––- ---- ----- To search fora participating <br /> Waived for Class I Services? Yes provider;contact Florida Combined <br /> Life's customer service or visit <br /> Calendar Year Benefit Maximum www.floridabluedental.com.When <br /> Per Member $1,000 –; completing the necessary search <br /> criteria,select BlueDental Choice Plus <br /> Class I Services:Diagnostic&Preventive Carenetwork. <br /> Routine Oral Exam(2 Per Calendar Year) 1. Plan Pays:100% <br /> ' <br /> Plan Pays:100%Routine Cleanings(2 Per Calendar Year) 7 Deductible Waived <br /> Deductible Waived ' (21 <br /> Bitewing X-rays(1 Per Calendar Year) (Subject to Balance Billing) <br /> Class II Services:Basic Restorative Care Plan References <br /> Complete Xrays j T <br /> "Out-of-Network Balance Billing: <br /> Fillings For information regarding out-of- <br /> network balance billing that may be <br /> Simple Extractions charged by an out-of-network provider, <br /> Deep Cleaning + Plan Pays:80%After CYD Plan Pays:80%After CYD please refer to the Out-of-Network <br /> (Subject to Balance Billing) Benefits section on the previous page. <br /> Endodontics(Root Canal Therapy) _ , <br /> [Periodontics <br /> Oral Surgery0 <br /> 1' <br /> Class Ill Services:Major Restorative Care <br /> Crowns Important Notes <br /> r Bridges •Each covered family member may <br /> -_ Plan Pays:50%After CYD receive upto two(2)routine deanin s <br /> f Plan Pays:50%After CYD 9 <br /> Dentures (Subject to8amnceBilling) per calendar year covered under the <br /> Implants preventive benefit. <br /> •For any dental work expected to cost <br /> Class IV Services:Orthodontia $200 or more,the plan will provide <br /> • — a"Pre-Treatment Review"upon the <br /> [Lifetime Maximum $1,000 <br /> request of the dental provider.This will <br /> IBenef t(Dependent Children Up to Age 26) Plan Pays:100%After CYD Plan Pays:100%After CYD assist with determining approximate <br /> (Subject to Balance Billing) ' out-of-pocket costs should employee <br /> have the dental work performed. <br /> •Waiting periods and age limitations <br /> may apply. <br /> •Benefit frequency limitations may <br /> apply to certain services. <br /> 90 <br /> 8 <br /> ©2016,Gehring Group,Inc.,All Rights Reserved <br />