Florida Safety Contractors

DENTAL INSURANCE

Florida Safety Contractors offers dental coverage through Florida Blue. The Dental PPO Plan allows you to use in- network or out-of-network benefits. If out-of-network dentists are used, you will be responsible for pay the difference between Florida Blue’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.

DPPO PLAN

In-Network Calendar Year Deductible Individual

$ $

Family

Annual Maximum (pre covered member) Per covered member

$

Preventive Services

Exams, Cleanings, & Fluoride

Covered in full

Basic Services

Fillings, Simple Extractions, & Periodontal Maintenance Major Services Crowns, Bridges, Perio, Endo, Surgical Extractions, Root Canal, & Dentures

__% after deductible

__% after deductible

Orthodontia

Child only

Member% $x,xxx lifetime maximum per person

Out-of Network 1

$ / $

Calendar Year Deductible Schedule of Services: Preventive Basic Major

__% after deductible __% after deductible __% after deductible

Member% $x,xxx lifetime maximum per person

Orthodontia

Annual Maximum (pre covered member)

$

90 th Usual & Customary Charges Bi-Weekly Cost for Coverage

Basis of Payment

$ $ $ $

Employee Only

Employee + Spouse Employee + Child(ren) Employee + Family

4 1 Subject to balance billing. Please refer to your plan document for specific details.

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