Dental Maximum Per Person at Any
Dentist You Choose
ü
Class 1 Plan $1000 per calendar year
ü
Class 2 Plan $1000 per calendar year
ü
Class 3
Plan $1,000 per calendar year
ü
Class 4 Plan
$1,000 per calendar year
Please refer to benefit
certificate for more detailed information.
Benefit certificates will be available after
your enrollment form has been processed.
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Elimination Period
ü
12 month waiting period on major procedures
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Dental
Deductible Per Person
ü
$50
calendar year - per person deductible
ü
Applies to
Basic
& Major Services only
Please refer to benefit
certificate for more detailed information.
Benefit certificates will be mailed after
your enrollment form has been processed.
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Schedule of Benefits
| Schedule of Benefits
(what the dental plan will pay) |
|
Sample Schedule of Benefits - How much the insurance will pay |
Class 1 |
Class 2 |
Class 3 |
Class 4 |
|
Plan Maximum Per Calendar Year-Per Person |
$1000 |
$1000 |
$1,000 |
$1,000 |
|
Preventive* - NO DEDUCTIBLE |
|
|
|
|
| Two evaluations
per calendar year |
100% |
100% |
100% |
100% |
| Two
cleanings per calendar year |
100% |
100% |
100% |
100% |
| Fluoride
for Children (Under age 19) |
100% |
100% |
100% |
100% |
| Space
Maintainers |
100% |
100% |
100% |
100% |
|
Radiographs (X-rays) |
100% |
100% |
100% |
100% |
|
Bitewings (Allowed twice per calendar year) |
100% |
100% |
100% |
100% |
|
Basic |
|
|
|
|
|
Sealant-per tooth (Coverage is limited to treatment of the occlusal
surface of permanent molar teeth once during a 3-year period) (Age 16 and
under) |
$18 |
$21 |
$21 |
$21 |
| Amalgam
restoration (silver fillings)—one surface, primary or permanent |
$41 |
$48 |
$48 |
$48 |
|
Extraction—Erupted tooth or exposed root (elevation and/or forceps
removal) |
$46 |
$54 |
$54 |
$54 |
| Surgical removal
of tooth (completely bony) |
$171 |
$200 |
$200 |
$200 |
| Denture repair-Repair
Broken Base |
$52 |
$61 |
$613 |
$61 |
| Deep
sedation/general anesthesia |
$131 |
$154 |
$154 |
$154 |
|
Major |
|
|
|
|
| Maxillary partial
denture—resin base |
$135 |
$166 |
$166 |
$166 |
| Endodontics—root
canal, anterior |
$105 |
$129 |
$129 |
$129 |
| Periodontal
scaling and root planning, limited (per quadrant). Each quadrant is
eligible for consideration once in a 2 year period |
$35 |
$43 |
$43 |
$43 |
| Crown—full cast
noble metal |
$152 |
$187 |
$187 |
$187 |
| Crown repair |
$29 |
$36 |
$36 |
$36 |
| Pontics—porcelain
fused to noble metal |
$156 |
$192 |
$192 |
$192 |
|
* Preventive benefits are paid at 100% of
the average charge in your zip codes area
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LIMITATIONS:
Covered Expenses will not include and no benefit will be payable for
expenses incurred:
- for
Major Procedures in the first twelve months that a person is insured.
- for any
procedure except exams, cleaning and fluoride applications for the first 12
months when an insured or dependent becomes classified as a late entrant.
If an insured or dependent does not enroll within 31 days from the date the
person qualifies for the insurance or who elected to become insured again after
canceling a premium contribution agreement will be classified as a late
entrant.
- for any
treatment which is for cosmetic purposes. Facings on crowns or pontics behind the second bicuspid
are considered cosmetic.
- to
replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed
partial denture within five years of the date of the last placement of these
items. However, if a replacement
is required because on an accidental bodily injury sustained while the person
is insured, it will be a Covered Expense.
- for
initial placement of any prosthetic appliance of fixed partial denture unless
such placement is needed because of the extraction of one or more natural teeth
while a person is insured.
The extraction of a third molar (wisdom tooth) will not qualify.
Any such appliance or fixed partial denture must include the replacement of the
extracted tooth or teeth.
- for any
procedure started before a person becomes insured.
- for any
procedure which began after a person’s insurance terminates; or for any
prosthetic dental appliances installed or delivered more than 90 days after a
person’s insurance terminates.
- to
replace lost or stolen appliances.
- for
appliances, restorations, or procedures to:
- alter
vertical dimension;
-
restore or maintain occlusion;
-
splint or replace tooth structure lost because of abrasion or attrition; or
- treat
disturbances of the temporomandibular joint (T.M.J.). (except in the states of Alabama,
Florida, Minnesota, Mississippi, and Washington)
- for any
procedure which is not shown on the List of Dental Procedures provided with
your Certificate of Insurance.
- for
education or training in, and supplies used for, dietary or nutritional
counseling, personal oral hygiene or dental plaque control.
- for the
completion of claim forms.
- for
orthodontic treatment.
- because
of any injury arising out of, or in the course of, work for wage or profit.
- by a
person because of a sickness for which he or she is eligible for benefits under
any Worker’s Compensation act or similar law.
- for
charges for which a person is not liable or which would not have been made had
no insurance been in force.
- for
services which are not recommended by a physician or which are not required for
necessary care and treatment.
- because
of war or any act of war, declared or not.
- by a
person if payment is not legal where the person is living when expenses are
incurred.
- for
sealants which are:
- not
applied to a permanent molar,
-
applied after attaining age 17,
-
reapplied to a molar within 3-years from the date of a previous sealant
application.
-
subgingival curettage or root planning (procedure numbers 4220 and 4341) unless
the presence of periodontal disease is confirmed by both radiographs and pocket
depth summaries of each tooth involved.
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