Health & Welfare BenefitTabs-bthw06

Category of Coverage	Plan Pays	In-Network Plan Pays	Out-Of-Network Plan Pays

Diagnostic & Preventive Benefit	100%	100%	80%

Basic Benefits (oral surgery, restorative treatment, Ondontics, periodontics)	80%	80%	80%

Crowns, jackets & Cast Restorations	80%	80%	80%

Prosthodontic Benefits	80%	80%	60%

Orthodontic Benefits	80%	80%	80%

Maximum	$3000	N/A	N/A

Maximum Orthodontics	$4000	$1500	$1500

Group Numbers	Active: #4874-0005 Retiree: #4874-0015

Contact Info	Mailing Address: P.O. Box 997330 Sacramento, CA 95899-7330 Online Customer Service Phone Number: 800-765-6003 FAX: 800-749-2227