Dental Plan . . .

The Health Trust offers one Dental plan to its member employer groups. Benefits are paid as follows:

Preventive & Diagnostic Services - 100% of Reasonable & Customary charges

Preventive services include: oral exams (two per calendar year), cleanings (two per calendar year), bitewing x-rays (two sets per calendar year), full mouth x-rays (one set every 36 months), fluoride treatments (to age 19), space maintainers (to age 19), sealants (to age 14)

Basic & Restorative Services - 80% of R&C, after deductible

Basic services include: extractions; extractions, oral surgery, fillings, general anesthetics (when medically necessary), periodontal treatment, endodontic treatment, and antibiotics.

Major & Prosthodontic Services - 50% of R&C, after deductible

Major services include: initial installation of bridgework, initial installation of partial or full removal dentures, inlays, onlays, crowns, gold fillings, repair or recementing of bridgework, dentures, crowns, onlays, dental implants.

Orthodontic services are not covered by the Health Trust Dental plan.

The calendar year deductible for the Health Trust Dental plan is $25 per person, with a maximum of $75 per family. The Health Trust will pay a maximum of $1,250 in benefits for each family member covered under the Dental plan.

There is no dental ID card provided if you are covered under this plan.

Please note: This is intended only as a summary of benefits. Please contact the Health Trust at 1-800-852-8300 for more information about any of the Health Trust plans.

Brochure

Updated 12/29/06