Lincoln Financial (formerly Jefferson Pilot) Group Dental Plan for Employees of Lexington City Schools
The following information is intended to be a summary of your Dental Plan. Please contact your Plan Administrator for a complete dental plan guide.
SUMMARY OF DENTAL BENEFITS
| General Provisions | |
| Annual Deductible Individual Family |
$50 $150 |
| Annual Deductible for Preventative | $0 |
| Calendar Year Maximum | $1,000 |
| Lifetime maximum for orthodontia | $1,000 |
| Diagnostic and Preventative | Percentage Paid |
| Routine Oral Exams | 100% Twice in any calendar year |
| Bitewing X-rays (dependents under age 18) | 100% Twice in any calendar year |
| Bitewing X-rays (insured's over age 18) | 100% Once in any calendar year |
| Full Mouth X-Rays (including bitewings) | 100% Once every 4 calendar years |
| Dependent Fluoride treatment (under age 16) | 100% Twice in any calendar year |
| Space Maintainers (dependents under age 14) | 100% Includes adjustments within 6 months |
| Basic and Primary Services | |
| Basic Restoration | 80% |
| Simple Extractions | 80% |
| Dependent Sealants (under age 17) | 80% Once per tooth in any 3 calendar years |
| Dependent Sealants (under age 17) | 80% Once per tooth in any 3 calendar years |
| Repairs to Dentures, Bridges, Crowns and Inlays | 80% 12 months after initial insertion |
| Endodontics (root canal, apicoectomy, pulp capping) | 80% |
| Anesthesia | 80% when required for complex oral procedures |
| Major Services | 12 Month Waiting Period |
| Periodontal Services: Scaling and root planing |
50% Once per quadrant in any 3 calendar years |
| Periodontal appliance (occlusal guard) | 50% |
| Major Periodontal Surgery | 50% Once per area of the mouth in any calendar year |
| Anesthesia | 50% When required for complex oral surgical procedures |
| Inlays, Onlays and Basic Crowns | 50% |
| Full and Partial Dentures | 50% |
| Fixed Prosthetics | 50% |
| Orthodontia* - Benefits paid at 50% | 12 Month Waiting Period |
*Benefit is available to dependent children up to age 19
Rates
| 10 Month Rates | 12 Month Rates | |
|---|---|---|
| Employee Only | $0 (Employer Paid) | $0 (Employer Paid) |
| Employee and Spouse | $30.32 | $25.27 |
| Employee and Child (ren) | $38.53 | $32.11 |
| Family | $75.50 | $62.92 |