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Connection Dental Plus Benefit Schedule

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The Benefit Schedule lists the Benefit Percentages, Deductibles, Maximum Benefit Limits and Waiting Periods applicable to each Class of Covered Services.

Do not rely on this chart alone. All benefits are subject to the definitions, limitations and exclusions set forth in the Connection Dental Plus® dental brochure.

Connection Dental Plus Benefit Schedule
Covered Services Calendar Year Deductible Waiting Period Provider Participation Benefit
Class A
Specified diagnostic & preventive
$0 None In-network
Out-of-network
100%
80%
Class B
Other diagnostic, preventive, restorative & specified oral surgery
$50 None In-network
Out-of-network
80%
70%
Class C
Endodontics, periodontics, prosthodontics & crowns, inlays, onlays
$100 12-month In-network
out-of-network
50%
40%
Class D
Orthodontics – comprehensive case (ages 6-17)
$0 24-month In-network
Out-of-network
$50 per month
$25 per month

Deductibles

  • Calendar Year Deductibles apply separately to Class B and Class C Covered Services. The Class B Deductible does not apply to or reduce the Class C Deductible.
  • Deductibles apply separately to each Covered Person.

Maximum Limits

  • Class A, Class B and Class C Covered Services have a combined Calendar Year Maximum Benefit Limit per Covered Person of $1,200.
  • Class D Covered Services have a Calendar Year Maximum Benefit Limit of $600 per Covered Child for treatment by a Participating Provider or $300 for treatment by a Non-participating provider and a Lifetime Maximum Benefit Limit of $1,200 per Covered Child toward treatment by a Participating Provider or $600 for treatment by a Non-participating Provider.

Waiting Periods

  • Waiting Periods apply separately to each Covered Person. If an Eligible Dependent's Effective Date of Coverage is later than the Member's Effective Date of Coverage, the Waiting Period for the Eligible Dependent begins on the Effective Date of Coverage for the Eligible Dependent.
  • Coverage for Class C Covered Services begins 12 months after the date the Member or Eligible Dependent is first covered under The Dental Plan.
  • Coverage for Class D Covered Services begins 24 months after the date the Covered Child is first covered under The Dental Plan.

Benefit Percentages

  • Benefit Percentages apply separately to each Covered Person. If an Eligible Dependent's Effective Date of Coverage is later than the Member's Effective Date of Coverage, the Benefit Percentages for the Eligible Dependent begin on the Effective Date of Coverage for the Eligible Dependent.