|Annual Deductible||$50.00 (Type II and Type III only)|
|Type I Services||Type II Services||Type III Services|
|Benefit||100% of UCR||80% of UCR||50% of UCR|
|Benefit Maximum||$1,500.00 per Policy Year per Covered Person*|
* Effective January 1, 2020
UCR - Usual, customary and reasonable - Commonly charged fees for dental services in a certain area.
The above information is provided as a summary only. For a detailed list of Type I, II, and III services, please refer to the Summary Plan Document.
|Employee + 1 Dependent||$6.51||$14.11|
|Employee + 2 or more Dependents||$13.11||$28.41|
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Please Note: Flexible Spending Accounts and Vision Insurance are not administered by TLC.