Trustmark Advantage Dental Plan
Washington
Benefit Maximum:
Per Person, Per Plan Year: $1500
Deductible:
(applies to class B & C services only)
Per Person, Per Plan Year: $50
Insured Percent:
| Class A | Class B | Class C | |
| 1st Yr | 100% | 80% | 25% |
| 2nd Yr | 100% | 80% | 50% |
| 3rd Yr | 100% | 80% | 50% |
Class A Services (No Waiting Periods)
- Routine Oral Exams (Once every 6 Months)
- Routine Dental Cleaning (Once every 6 Months) (Frequencies combined with periodontal maintenance)
- Bitewing x-rays (once every 12 months)
- Flouride treatments* (once every 12 months)
- Sealants* -once per permanent molar every 3 years.
- Space maintainers* - includes adjustments.
- Harmful habit appliances-once per person *limited to children under age 16
Class B Services (No Waiting Periods)
- X-rays: - Complete mouth or panoramic - (once every 60 months), -Other x-rays
- Emergency Exams
- Fillings
- Simple extractions
- Certain lab tests, pain treatment, therapeutic drug injections
Class C Services (No Waiting Periods)
- Covered treatment due to accidental non-chewing injuries
- Adjustment and repairs to: Dentures, Crowns, Inlays, Onlays, Fixed Bridgework
- Endodontics
- Minor Periodontics
- Denture Relines/Rebases
- Fixed Bridgework
- Complex Oral Surgery and Anesthesia
- Major Periodontics
- Full and Partial Dentures
- Crowns Inlays, Onlays
- Fixed Bridgework
Other Policy Provisions:
Effective Date:
The effective date for this group is August 1, 2006. Your individual effective date may differ depending on when your enrollment form is received. The rates shown below are guaranteed for 12 months from the group's effective date.
Takeover
If you and your dependents (if applicable) were coverd by the prior plan for Class C service as of June 30, 2006, your Class C Insured Percent would begin with the 3rd year percentage. If you and your dependents (if applicable) were not covered by the prior plan on that date, your Class C Insured Percent would begin with the 1st year percentage.
Eligibility
Full-time, active employees; legal spouse; unmarried children to age 19; age 23 if full-time student.
Prevailing Fee
Amount allowed for covered services is based on the Prevailing Fee (usual & customary). The Prevailing Fee is based on the general level of charges for similar procedures, service and supplies made by dentists in the area where your dentist practices.
Bi-Monthly Deductions
| Employee Rate | $22.88 |
| Emp + Spouce Rate | $45.03 |
| Emp + Child(ren) Rate | $45.03 |
| Family Rate | $66.16 |
Limitations and Exclusions
No benefits are payable for: replacement of natural teeth missing on effective date of insurance, care that your Certificate, not professionally endorsed; experimental or cosmetic in nature; TMJ disorders, implants, vertical dimension, bite registration; loss due to war, riot, felony, or assault.
