| GBA Insurance Trust, Inc. | |||
| 2010 Summary of Dental Benefits for Plan # 275 | |||
| Calendar | |||
| Individual | $100 | ||
| Family | $300 | ||
| Annual Maximum Benefit (per person) | $1,250 | ||
| Preventive & Diagnostic (deductible waived) | 100% | ||
| Includes 2 oral exams, cleanings & x-rays per year | |||
| Basic Dental Services | 80% | ||
| Includes oral surgery, root canals, fillings, etc. | |||
| Major Dental Services | 50% * | ||
| Includes crowns, bridges, & dentures | |||
| Orthodontic Services | Children Under Age 19 Only | ||
| Percentage | 50% | ||
| Lifetime Maximum Benefit | $1,000 | ||
| For more information: | |||
| Dentist Network on the Internet | www.bcbsga.com | ||
| Paragon Customer Service | 877-380-0193 | ||
| Claims on the Internet | www.paragonbenefits.com | ||
| Plan Certificates | www.gabankers.com/GBAIT/gbaithome.asp | ||
| *
No benefits will be paid for major services for the first 12 months. **Reimbursements subject to usual & customary & reasonable limitations Credit will be given for those employees covered under their prior plan. Late enrollees will not have major services for the first 18 months. Voluntary participation; payroll deduction under the Section 125 Plan. Dependents covered only if the employee is covered. |
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