Pittsburgh Technology Council
August 28, 2008
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2003 Dental Benefits Option IV

Coverage

Following is a summary of the coverage levels, terms and conditions for Option IV Dental Plan offered by the Council's Employee Benefits Group.

Benefits at a Glance
Option IV
Preventive Services
Diagnostic 100%
Preventive 100%
Basic Services
Basic Restorative 100%
Endodontics 100%
Simple Extractions 100%
Oral Surgery 100%
Non-Surgical Periodontics 100%
Surgical Periodontics 100%
Major Services
Crowns, Inlays, Onlays 60%
Fixed Prosthetics 60%
Removable Prosthetics 60%
Orthodontics
(Dependents under Age 19)		 60%
Yearly Deductible $50
Lifetime Maximum $1,000
Deductibles
Program Calendar Year Deductible: $25 Except Preventive
Program Calendar Year Maximum: $1,500 per person

Payment of benefits is based on the Usual, Customary, and Reasonable (UCR) charges as determined by Highmark Blue Cross Blue Shield.This description outlines the principal features of the dental programs offered by the Council's Employee Benefits Group. It is not to be considered the contract of benefits and provisions. The complete terms of coverage are set forth in agreements issued by the individual carriers.

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Provider Network

Members can use the  Provider Network Directory provided by United Concordia, Inc. and select "Penn Dental" to search for participating dentists your area.

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Rates

The rates listed below include a 3% administrative fee and are guaranteed to December 31, 2003.

Monthly Premium Rate Option IV
Individual $25.57
Family $77.13

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If you have any further questions, please contact us; we'll be glad to help you.

This information is not intended for use without professional advice. While we have attempted to make this site as accurate as possible, it is only a summary. For more information, see our disclaimer.


Last updated on:  Thursday, November 04, 2004  Page: 

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