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FOR EMPLOYEES AND NON-MEDICARE-ELIGIBLE RETIREES
53
Note:
1 All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in- and out-of- network.
2 Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed.
3 *Subject to annual deductible
4 **In addition to the amount you pay as indicated in this column, if the out-of-network provider charges a total that is higher than the 90th percen-
tile of reasonable and customary allowances, the provider generally will also bill you for that additional amount.