Natural Body Benefit Guide

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YOUR DENTAL PLAN
D E N T A L
B E N E F I T S
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1-877-330-5973 or
Group #: GA 6033
Plan Name: Natural Body
Deductible In Network Out of Network
Individual $50 $50
Family $150 $150
Calendar Year Maximum $1,000 $1,000
Deductible Waived for Preventive No No
Preventive Services
- Initial oral exams
-Periodic oral exams
-Bitewing X-rays
-Prophylaxis (cleanings)
Plan pays 100%
after Deductible
Plan pays based on Fee
Schedule
Basic Restorative Services
- Fillings
- All other X-rays
Plan pays 50%
after Deductible
Plan pays based on Fee
Schedule
Major Restorative Services
-Crowns - Oral Surgery
-Dentures - Simple Extractions
-Root Canals -Periodontics
Plan pays 50%
after Deductible
Plan pays based on Fee
Schedule
Orthodontic Services Not Covered Not Covered
Oral Surgery
All Other Major Services
6 months
12 months
6 months
12 months
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
$10.02
$20.06
$19.04
$30.08
Blue Cross Blue Shield of Georgia
Type of Dental Service
Benefit Waiting Periods (for new members)
Employee Contributions (per pay period)