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Plan Description
Dental Services > Dental DMO Plan
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Note: This page contains a brief summary of coverage. It does not
state all provisions and limitations of the plan. The terms and provisions of
each plan, as outlined in the plan document, will determine coverage and
eligibility.
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General Plan Information
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Annual Deductible
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- Individual
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$0
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- Family
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$0
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Deductible Waived for Preventive
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Yes
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Annual Plan Maximum
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$1,500
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Lifetime Orthodontia Plan Maximum
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$1,000
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Reasonable & Customary
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75%
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Waiting Period
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60 days
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Diagnostic and Preventive Services
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Diagnostic and Preventive
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100%
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Oral Exams
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100%
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Bitewing X-Rays
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80%
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Prophylaxis Treatments
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80%
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Fluoride Treatments
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80%
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Space Maintainers
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50%
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Sealants
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50%
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Waiting Period Information
Eligible employees are eligible as of the 1st of the month following the employee's hire date.
Termination of Coverage Information
When a plan participant is terminated from the company, the plan coverage ends on the last day of the month following the employee's termination date.
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(per month)
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Employee
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$90.80
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Employee + Spouse
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$24.32
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Employee + Child(ren)
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$45.32
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Family
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$154.15
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Dental DMO Plan
Member Services
John Carpet
P.O. Box 173
Detroit, MI
80217
303-741-9300
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