Summary of benefits



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Group Dental Insurance

SUMMARY OF BENEFITS





Wabash College

Effective date:

January 01, 2011



All Benefits Eligible Employees as defined by the College


  • By enrolling in the dental plan you and your enrolled family members will have access to
    Lincoln DentalConnectSM, our free on-line dental health information Web site.

  • If you incur dental expenses and have satisfied the benefit waiting period(s), the plan pays the following percentage of allowable expenses in excess of the deductible up to the maximum benefit.

  • Covered dental expenses include only those services listed in your certificate.

  • Covered expenses outside the panel service area will not exceed the policy’s usual and customary allowances.










In-Network

Out-of-Network

Preventive

- Routine Oral Exams

- Bitewing X-rays

- Routine Cleanings

- Fluoride Treatments

- Space Maintainers for children

- Sealants



100%

100%

Basic

- Full-mouth or Panoramic X-rays

- Other Dental X-rays (including periapical films)

- Problem Focused Exams

- Consultations

- Palliative Treatment (including emergency relief of dental pain)

- Injections of antibiotics and other therapeutic medications

- Fillings (includes composite fillings on posterior teeth)

- Prefabricated Stainless Steel and Resin Crowns

- Simple Extractions

- Surgical Extractions

- Oral Surgery

- Biopsy and Examination of Oral Tissue (including brush biopsy)

- General Anesthesia and I.V. Sedation

- Prosthetic Repair and Recementation Services

- Periodontal Maintenance procedures


80%

80%

Major

- Endodontics (including Root Canal Treatment)

- Non-surgical Periodontal Therapy

- Periodontal Surgery

- Bridges

- Full and Partial Dentures

- Denture Reline and Rebase Services

- Crowns, Inlays, Onlays and related services

- Implants and related services



50%

50%

Orthodontics

- Orthodontic Treatment- Including Orthodontic Exams, X-rays, Extractions, Study Models and Appliances

50%

50%

Deductible

Calendar year deductible. Waived for Preventive services

$50 Individual

$150 Family



$50 Individual

$150 Family



Maximum

Calendar year maximum for Preventive, Basic and Major services

$1000

$1000

MaxRewardsSM

A covered person may be eligible for a rollover of a portion of the previous year's unused Annual maximum for Preventive, Basic and Major services combined based on the following:




Eligible Range (claim threshold)

$1 - $500




Rollover Amount

$250 per calendar year




Maximum Rollover Account Balance

$1000

Ortho Maximum

Lifetime Ortho Maximum for family

$1000

$1000


Your plan costs

Employee only

$31.67

Monthly

Employee and Spouse

$62.24

Monthly

Employee and Children

$74.26

Monthly

Family

$107.02

Monthly


Enrolling for coverage

If you do not want to enroll at this time, submit the completed waiver form to your plan administrator. If you waive coverage now and want to enroll at a later date, you will be subject to the plan’s Late Entrant provision.


Dependent eligibility

Unmarried dependent children may be covered to age 26.




Benefit waiting period




Basic services:

None

Major services:

None

Orthodontia

12 Month Waiting Period for New Hires


If prior carrier credit is included

  • Available to employees and dependents if your coverage was active on the date your employer’s prior dental plan terminated, and if you are covered by this plan on its effective date.

  • Credit will be given for dental expenses incurred toward satisfying your deductible under your employer’s prior dental plan during the same calendar year.

  • Credit will be given for the time you have been covered by your employer’s prior dental plan toward the satisfaction of benefit waiting periods.

  • Benefits paid by your employer's prior dental plan during the same calendar year will be applied toward your maximum.


Exclusions

This is a summary of policy exclusions. The policy contains other, more specific, exclusions and limitations not fully explained in this benefit summary.



  • The plan does not cover services started before coverage begins or after it ends. Services must be necessary and appropriate for the claimant’s condition. Benefits are limited to services specifically shown on the list of procedures included in the policy, unless coverage for additional services is required by state law. Benefits are not payable for duplication of services or for treatment by a practitioner who lives with or is related to the employee or dependent.

  • Benefits are not payable for placement of a prosthetic, unless it is needed to replace teeth extracted while covered. Policy does not cover the cost of athletic mouth guards, appliances to correct harmful habits or the replacement of lost or stolen dental appliances. Policy excludes services for treatment of TMJ or congenital malformations, except as required by law.

  • Benefits are not payable for veneers, cosmetic procedures or medications administered outside the dentist’s office, for prescription drugs, or for analgesia, sedation, hypnosis or acupuncture administered for the purposes of alleviating anxiety or apprehension. Nitrous oxide is not covered.

  • Plan benefits are not payable for a condition for which the claimant is eligible for benefits under worker’s compensation or a similar law; or for a condition attributed to employment or military service. Coverage is not available for dental conditions caused by an act of war, self-inflicted injury, involvement in an illegal occupation, attempt to commit a felony, or active participation in a riot.

  • If benefits for orthodontia are included, the plan does not cover any treatment plan started before coverage begins or during the benefit waiting period unless the member was receiving orthodontia benefits from this employer’s previous group dental policy. In that case, Lincoln Financial will continue orthodontia benefits until the combined benefit paid by the two policies is equal to this policy’s lifetime orthodontia.


Alternative benefits provision

In certain situations there may be two or more methods of treating a dental condition. Your policy includes an alternative benefits provision that may reduce benefits to the lowest cost, generally effective and necessary form of treatment.


Late entrants

If you enroll more than 31 days after becoming eligible, you will be subject to the plan’s Late Entrant limitation and Prior Carrier Credit will not be available.


Predetermination of benefits

Allows you to find the amount covered prior to having a dental procedure. We recommend that you use this service when expenses are expected to exceed $300.


Claim submission

Submit a claim by mail to:

Submit a claim by fax to:

Lincoln Financial Group

Dental Claims Input Center

P.O. Box 614008

Orlando, FL 32861-0001



(877) 843-3945


For assistance or additional information

Contact Lincoln Financial Group at 800-423-2765 or log on to www.LFG.com.


NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.

©2008 Lincoln National Corporation

Group Insurance products are issued by The Lincoln National Life Insurance Company (Ft. Wayne, IN), which is not licensed and does not solicit business in New York. In New York, group insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Each affiliate is solely responsible for its own financial and contractual obligations.


ROCLCOLE WABCOL WACOC922NW20101124 1.01

2016/11/26




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