Ameritas Dental/Vision Plans for NFU

 

 

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Dental Benefits - % Plan

Dental Rates-Scheduled Plan

Vision
Schedule of Benefits for % Plan
Dental Maximum Per Person at Any Dentist You Choose
ü       $1,000 per benefit period
ü       Of this maximum benefit, no more than $500 per benefit period will
      paid on major procedures

ü       Benefits may be subject to usual & customary

 

Dental Deductible Per Person
ü       $50 per benefit period

 

 

80% Coverage for Preventive Dental Services after Deductible

ü       One evaluation per benefit period

ü       Two cleanings per benefit period

ü       Floride treatment for children under age 14

ü       One bitewing x-ray once every 12 months

 

80% Coverage for Basic Dental Services after Deductible
ü       Radiograph x-rays once every 5 years
ü       Sealants for children under age 14. 
      One treatment per permanent molar tooth        

ü       Limited exams for focused problem

ü       Restorative amalgams & Resin (Fillings)

ü       Oral surgery - simple extraction
 
Increasing Benefit* for Dental Major Services after Deductible
ü       Space maintainer for children
ü       Anesthesia & oral surgery, complex extraction      

ü       Limited exams for focused problem

ü       Stainless steel crowns

ü       Restorative inlays & crowns

ü       Root canals, gum disease and Prosthodontics

 

 

* Major Service are paid at 10% coinsurance-1st year, increases to %25%-2nd

  year, increases to %50-3rd year & thereafter.  Of the maximum benefit, no

  more than $500 per benefit period will be paid on major services.

 

      Vision Benefits

      Vision Benefits at Vision Service Plan (VSP) Providers with No Deductible

ü       %100 coverage for one routine vision exam

         for each insured once per 12 month period     

ü       20% discount off a complete pair of frames and lenses      

ü       %15 discount off contact lens services

ü       An average discount of 10-25% off laser vision correction surgery for PRK

      or LASIK at a VSP provider

ü       There are over 29,000 providers in the United States
 
 
* Please refer to your certificate for complete details on all benefits, frequencies, and plan
 limitations.   A certificate will be mailed after your enrollment form has been processed.
Limitations

             Covered Expenses will not include and no benefit will be payable for expenses incurred:

  1. for Major Procedures in the first twelve months that a person is insured. 
  2. 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.
  3. for any treatment which is for cosmetic purposes.  Facings on crowns or pontics behind the second bicuspid are considered cosmetic.
  4. 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. 
  5. 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.
  6. for any procedure started before a person becomes insured.
  7. 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.
  8. to replace lost or stolen appliances.
  9. for appliances, restorations, or procedures to:
    1. alter vertical dimension;
    2. restore or maintain occlusion;
    3. splint or replace tooth structure lost because of abrasion or attrition; or
    4. treat disturbances of the temporomandibular joint (T.M.J.).  (except in the states of Alabama, Florida, Minnesota, Mississippi, and Washington)
  10. for any procedure which is not shown on the List of Dental Procedures provided with your Certificate of Insurance.
  11. for education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control.
  12. for the completion of claim forms.
  13. for orthodontic treatment. 
  14. because of any injury arising out of, or in the course of, work for wage or profit.
  15. 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.
  16. for charges for which a person is not liable or which would not have been made had no insurance been in force.
  17. for services which are not recommended by a physician or which are not required for necessary care and treatment.
  18. because of war or any act of war, declared or not.
  19. by a person if payment is not legal where the person is living when expenses are incurred.
  20. for sealants which are:
    1. not applied to a permanent molar,
    2. applied after attaining age 17,
    3. reapplied to a molar within 3-years from the date of a previous sealant application.
  21. 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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