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Southern National Life Insurance Company Dental Direct Plan ZACHARY COMMUNITY SCHOOL BOARD – 09/01/2014 RENEWAL Covered Services: Pays up to $1,500 Annual Benefit for Certain Procedures. Type II Basic Services Type III Major Services Type IV Orthodontic Services No Deductible Deductible Applies* Deductible Applies* No Deductible Routine Exams Restorative Restorative (inlays & crowns) Bitewing X-rays (one per 6 months) (one series per 36 months) Basic Fillings Prosthetics (dentures & bridges) Orthodontia (for proper alignment of teeth) Oral Surgery (extractions & impacted teeth) Periodontal Surgery Type I Preventive Services Prophylaxis Sealants (to age 14) Endodontics (root canal & pulpal therapy) Denture & Crown Repair Periodontics (treatment of gums including surgery) Orthodontia is provided only to dependent children who are under age 21 when treatment is received. $500 Annual Maximum Fluoride Treatments (to age 15) $1,200 Lifetime Max. Space Maintainers (to age 9) Certain Lab Tests Emergency Palliative Treatment Flat Benefits-no/100% OPTION 1 BENEFITS Flat Benefits- 6 month waiting 50% Flat Benefits- no/80% Flat Benefits- 12 month waiting * Deductible is $75 per person/$225 per family per calendar year. waiting Employee Participation Requirement: (Percentage100% based on number of full-time employees) 25 – 149 lives………………………………………………………………………………………...….35% waiting more than 150 lives…………………………………………………………………………………...…25% Maximum Benefit: Annual Maximum 80% per Employee RATES: Employee only Employee and Spouse Employee and Children Employee and Family $1,500 $38.67 $76.62 $85.89 $122.20