2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 88
DENTAL SCHEDULE OF BENEFITS
DENTAL BENEFITS
Plan Pays
Covered Person Pays
(Subject to Usual &
Customary Charges)
CALENDAR YEAR DEDUCTIBLE
Per Individual
DENTAL BENEFITS
Class A Expenses (Preventive Services)
$0
$50
100%
$0
Class B Expenses (Basic Services)
80%
20% after Deductible
Class C Expenses (Major Services)
80%
20% after Deductible
Class D Expenses (Orthodontia)
80%
20% after Deductible
CALENDAR YEAR MAXIMUM BENEFIT
(Classes A, B, C, and D Expenses combined
per person)
$1,500
(Class A Expenses are not applied to the Calendar
Year Maximum for those persons under age 19)
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