SCHEDULE OF DENTAL EXPENSE BENEFITS
CITY OF LEWISVILLE
Plan Benefits Effective: October 1, 2010
| Maximum Benefit for Preventative, Basic and Major | $1,250 |
| Maximum Benefit for Child Orthodontic | $1,000 |
| Waiting Period |  |
| Major Services | 1 year |
| Orthodontic Services | 2 years |
| Calendar Year Maximums | |
| Preventative Care | 100%, no plan deductible |
| Office Visit, Oral Examination | 2 visits |
| Prophylaxis under age 14 | 2 treatments |
| Prophylaxis age 14 or over | 2 treatments |
| X-rays - Complete Series | 1 every 3 years |
| Topical Application for Fluoride (including prophylaxis) | 1 treatment |
| Bitewing X-rays | 2 times per year |
| Sealants (for individuals 19 or under) | 1 every 3 years |
| Fixed Space Maintainer (limited to nonorthodontic treatment) | |
| Deductible for Basic and Major for Individual | $50 |
| Deductible for Basic and Major for Family | $150 |
| Pre-determination is recommended on all services of $300 or more | |
BENEFIT PERCENTAGE PAYABLE AFTER DEDUCTIBLE
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