Who is Eligible for Coverage. Dependent Children Children are covered until the first day of the month following their 19th birthday. This is a summary of your dental benefit coverage levels under this agreement. It includes information about coinsurance, deductibles, and visit limits. This summary is intended to give you a general understanding of the dental coverage available under this agreement. For more detailed information, please read Section 3.0 for the description of coverage for each particular covered service along with the related exclusions, and Section 4.0 for a list of general exclusions. Words or phrases used throughout this agreement that are in italics are defined in Section 8.0 - Glossary. The level of coverage and benefit limits are based on the age of the enrolled member. For members under the age of 19: In accordance with PPACA, this agreement provides coverage for the dentally necessary and medically necessary services listed in the columns of the Summary of Benefits labeled “MEMBERS UNDER THE AGE OF 19”. If an enrolled member turns 19 years old during the benefit year and continues to be a member under this agreement, this plan will not cover services in excess of the annual maximum benefit or benefit limits listed for “MEMBERS 19 YEARS OLD AND OLDER”. Services previously provided, during the benefit year, are counted in determining whether the annual maximum benefit or benefit limits have been met. For members age 19 and older:
Who is Eligible for Coverage. Dependent Children Unmarried dependent children are covered until January 1st following their 19th birthday. Dependent Students Unmarried dependent children are covered until January 1st following their 25th birthday when enrolled as a student and financially dependent upon you. If student status ends, coverage will end the first day of the month following the end of student status. Deductible per calendar year The deductible applies to all covered expenses, with the exception of certain preventive care services. The deductible applies to network provider and non- network provider services separately. Single $5000 per individual per calendar year. $5000 per individual per calendar year. Family The family deductible is met by collectively adding the amount of covered health care expenses applied to the deductible for all eligible family members. $10000 per family aggregate per calendar year. $10000 per family aggregate per calendar year. Maximum Out-of-Pocket Expense per calendar year The deductible and copayments apply to the maximum out-of-pocket expense. Single $10000 per individual per calendar year. Family The family maximum out-of- pocket expense is met by collectively adding the amount of covered health care expenses applied to the deductible and copayment for all eligible family members. $20000 per family aggregate per calendar year.
Who is Eligible for Coverage. Dependent Children Children are covered until the first day of the month following their 26th birthday. WELLNESS REWARD PROGRAM
Who is Eligible for Coverage. Dependent Children Children are covered until the first day of the month following their 26th birthday. SUMMARY GRP (09-10) Summary of Benefits Continued Summary of Medical Benefits See Important Note from First Page Type of Service Section Benefit Limit Level of Coverage Network Provider Non-Network Provider Deductible The deductible applies to both network and non-network services separately. Single $250 per member per contract year $1,000 per member per contract year. Family $500 per family per contract year. $2,000 per family per contract year. The contract year family deductible is met by adding the amount of covered health care expenses applied to the deductible for all family members; however no one (1) family member can contribute more than $250 towards the contract year family deductible. The contract year family deductible is met by adding the amount of covered health care expenses applied to the deductible for all family members; however no one (1) family member can contribute more than $1,000 towards the contract year family deductible.
Who is Eligible for Coverage. A person who has arranged to take a Covered Trip, and pays the required plan payment, and is a citizen or resident of the United States of America. All coverage will take effect on the date and time you start your Covered Trip. Your coverage automatically ends on the earlier of:
