| GBA Insurance Trust, Inc. |
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| 2010 Summary of
Dental Benefits for Plan # 274 |
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| Calendar Year
Deductibles |
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Individual |
$100 |
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Family |
$300 |
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| Annual
Maximum Benefit (per person) |
$1,250 |
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| Preventive &
Diagnostic (deductible waived) |
100% |
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Includes 2 oral exams,
cleanings & x-rays per year |
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| Basic
Dental Services |
80% |
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Includes oral surgery,
root canals, fillings, sealants etc. |
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| Major
Dental Services |
50% |
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Includes crowns, bridges, & dentures |
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| Orthodontic
Services (Adult and Children) |
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Percentage |
50% |
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Lifetime maximum benefit |
$1,000 |
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| For
more information: |
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Dentist Network on
the Internet |
www.bcbsga.com |
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Paragon Customer Service |
877-380-0193 |
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Claims on the Internet |
www.paragonbenefits.com |
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Plan Certificates |
http://www.gabankers.com/GBAIT/gbaithome.asp |
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| *Reimbursements
subject to usual & customary & reasonable limitations |
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| Late enrollees will
not have major or orthodontic services for the first 18 months. |
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| Employee must be
covered under dental coverage in order to insure dependents for dental
coverage |
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| Dental Coverage is
available for employees and dependents with or without medical insurance |
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