Page 42 - The Legacy School Benefit Booklet 2021-2022

Dental Benefits

The Legacy School provides Dental benefits through the following plan:
CareFirst Blue Dental Plus Plan 5
» Choose from a large national network to participating dentists.
» In-Network and Out-of-Network coverage

» Please refer to summary plan description for more details and for cost breakdown refer to
“Frequently Asked Questions”.

Dental Summary

CareFirst Blue Dental Plus
Benefits
Plan 5
In-Network
Referral Needed No
Class I
Preventive/Diagnostic Pd @ 100%

Class II Deductible then
Basic Services Pd @ 80%
Class III Deductible then
Major Services - Surgical Pd @ 80%
Class IV Deductible then
Major Services - Restorative Pd @ 50%

Class V
Orthodontic Services - Lifetime Maximum 50% of Allowed Benefit After Deductible

Deductible (Class II, III & IV)
Individual $25
Family $75

Out-of-Network
Class I
Preventive/Diagnostic Pd @100%
Class II Deductible then
Basic Services Pd @ 80%
Class III Deductible then
Major Services - Surgical Pd @ 80%

Class IV Deductible then
Major Services - Restorative Pd @ 50%

Class V 50% of Allowed Benefit After Deductible
Orthodontic Services - Lifetime Maximum

Deductible (Class II, III & IV)
Individual $50
Family $150