Download Flat Benefits - Zachary Community Schools

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