This deductible applies to Type  II and III services

Payment is based upon allowable charges in the area in which service is rendered. 
Full Plan Benefit at any Dental Office (PPO offices offer additional discounts).

TYPE I (Preventive SERVICES) 100%

TYPE III (Major SERVICES) 50%

Including:

• Routine Exams
• Prophylaxis (cleanings-one per 6 months)
• Emergency exams for dental pain (minor procedures)
• Fluoride treatments for dependent children under age 19 (one per 12 months)
• Bitewing X-rays (once per 6 months)

Including:

• Major restorative services (crowns and inlays)
• Prosthetics (bridges, dentures)
• Replacement of prosthodontics, dentures, crowns and inlays
• Denture relines
• Space maintainers
• General anesthesia (for services dentally necessary)

TYPE II (Basic SERVICES) 80%

Including:

• Periapical X-rays
• Full mouth or panorex X-rays (one per 36 months)
• Simple restorative services (fillings)
• Simple extractions
• Palliative treatment for dental pain, local anesthesia
• Sealants for children ages 6-15 (one per tooth)
•  Endodontics/root canal therapy
•  Periodontics
•  Oral Surgery

Orthodontics 50% to $1,500 Lifetime to age 19

Monthly Rates for NACS-FSA Members

Marketed by:
——————————————————————————————
Benefits-Direct
P.O. Box 10190
Kansas City, MO 64171
(800) 330-6223  - (816)841-3597
FAX: (816)841-3790

Claims Administration:——————————————————————————————

Liberty Dental
Po Box 26110
Santa Ana, Ca 92799-6110
 1(888) 902-0346

For Complete Details, Limitations, and Exclusions please see actual dental policy provided to you by Liberty Dental