MS Farm Bureau DENTAL

Services Covered	PPO/Premier	PPO/Premier	PPO/Premier
Services Covered	Year 1 Plan Pays	Year 2 Plan Pays	Year 3 Plan Pays
Type 1: Diagnostic & Preventive Services Oral exams X-rays Cleanings Fluoride treatments Space maintainers	100%	100%	100%
Type 2: Basic Services Simple extractions, fillings Palliative care Denture repair Sealants General anesthesia	50%	80%	80%
Type 3: Major Services Endodontics Periodontics Complex oral surgery Crowns, Inlays/Onlays, Bridges, Dentures	25%	50%	50%
Waiting Period	None	None	None
Annual Deductible (per person)	$50	$50	$50
Deductible waived on D&P?	No	No	Yes
Annual Maximum (per person)	$1,000	$1,000	$1,000
Monthly Rates
Member	$38.61
Member + 1 dependent	$75.02
Member + Family	$104.10

Rates include a $2.00 per month billing fee.

PPO/Premier – Pays the PPO fee schedule in network/pays the Premier (UCR) fee schedule to Delta Premier and non-network dentists.

This represents a summary of benefits. Complete information regarding limitations and exclusions will be included in the contract and member booklets.