Small Group Plan Designs Dental Plans

*Authorized Agent

Description of Benefits		Small Group Dental Plan Options
		2	20	28	35	36	85	86	87	88	89
Annual Deductible (per member-max 3 members)		$50	$50	$50	$25	$50	$25	$50	$50	$25	$50
Annual Maximum (per member-max 3 members)		$1,000	$1,500	$1,000	$1,500	$1,500/ $1,500 Orthodontic lifetime maximum	$1,000	$1,500	$1,000	$1,500	$1,000
Dental Coinsurance	Preventive (deductible waived)	100%	100%	100%	100%	100%	100%	100%	100%	80%	80%
	Basic Services	80%	80%	80%	80%	80%	80%	80%	80%	50%	50%
	Major Services (1 yr. wait if no prior group cov. within 90 days)	50%	50%	50%	50%	50%	50%	50%	50%	50%	50%
Orthodontic Coverage	Deductible	No Ortho	No Ortho	$50	$25	$50	$25	No Ortho	$50	$25	No Ortho
	Coinsurance			50%	50%	50%	50%		50%	50%
Note: Plan benefits listed above are intended as a summary only and do not replace benefits listed in certificate of coverage. Some specific benefits may have limitations and/or exclusions. Refer to your policy for more detail.
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*Blue Cross and Blue Shield of Georgia is an independent licensee of the Blue Cross Blue Shield Association