400
Effective Date of member's dental coverage
% (percentage) in and out of network (when applicable) or advise method of payment (Fee Schedule, Co-Pay, etc.)
NOTE: When providing benefits to EE/Dependent and mentioning the PDP fee add the wording unless additional charges are permitted by state law
Deductible and Maximum and what will each applies to
If Ortho is needed, also include Method of Payment (e.g., Monthly, Lump Sum, etc.)
Advise procedures may be subject to review and suggest pretreatment estimate
Required Scripting: "Please note, the plan has certain limitations and/or guidelines. Certain procedures may be subject to review, we suggest a pre-treatment estimate"
If applicable, advise if last FMX (full mouth xray) includes bitewing xrays it could affect bitewing frequency limitation
What is the short checklist