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Sample Schedule of Benefits of how much the insurance will pay There are over 250 covered procedures, below is only a sample. Supplemental Plan 1 Supplemental Plan 2 Economy Value 100/80/50 Calendar Year Deductible $50 for Basic/Major $50 for Basic/Major $50 for Basic/Major $50 for Basic/Major $50 for Basic/Major Waiting Period None None 12 Months - Major 12 Months - Major 12 Months - Major Plan Maximum Per Calendar Year Per Person $1,000 $1,000 $750 (of which $350 max. on    Major Procedures) $750 (of which $350 max. on    Major Procedures) $1,000* Preventive * - NO DEDUCTIBLE           Two cleanings per calendar year No Coverage No Coverage $28 each $39 each 100% Two exams per calendar year No Coverage No Coverage $11 each $16 each 100% One fluoride treatment per calendar year No Coverage No Coverage $11 $15 100% Basic           Panoramic X-rays No Coverage No Coverage $34 $47 80% Bitewing x-rays No Coverage No Coverage $12 $17 80% Fillings—one surface, permanent $40 $44 $29 $41 80% Extraction—single tooth $45 $49 $34 $47 80% Surgical removal of tooth $93 $117 $70 $98 80% General anesthesia $120 $175 $98 $137 80% Major           Maxillary partial denture $177 $222 $210 $293 50% Denture repair $43 $54 $25 $35 50% Endodontics $138 $173 $112 $156 50% Periodontal scaling $46 $58 $36 $51 50% Crown—full cast noble metal $200 $250 $157 $218 50% Crown repair $43 $54 $42 $59 50% Pontics—porcelain fused to noble metal $206 $257 $157 $218 50%                                                                                                                                   *Please refer to your certificate of insurance for complete details on all benefits, frequencies and plan limitations or view the limitations below

Ameritas Group Dental and Eye Care - Dental Limitations and Exclusions for all three dental plans:

Covered Expenses will not include and benefits will not be payable for expenses incurred: 

1. for Type 3 Procedures in the first 12 months the person is covered under this contract

2. in the first 12 months that a person is insured if the person is a Late Entrant; except for evaluations, prophylaxis (cleanings), and fluoride application.

3. for initial placement of any prosthetic crown, appliance, or fixed partial denture unless such placement is needed because of the extraction of one or more teeth while the insured person is covered under this contract. But the extraction of a third molar (wisdom tooth) will not qualify under the above.  Any such prosthetic crown, appliance, or fixed partial denture must include the replacement of the extracted tooth or teeth

4. for appliances, restorations, or procedures to:  a. alter vertical dimension; b. restore or maintain occlusion; or c. splint or replace tooth structure lost as a result of abrasion or attrition

5. for any procedure begun after the insured person's insurance under this contract terminates or for any prosthetic dental appliances installed or delivered more than 90 days after the Insured's insurance under this contract terminates

6. to replace lost or stolen appliances

7. for any treatment which is for cosmetic purposes

8. for any procedure not shown in the Table of Dental Procedures.  (There may be additional frequencies and limitations that apply, please see the Table of Dental Procedures for details.)

9. for orthodontic treatment under this benefit provision.  (If orthodontic expense benefits have been included in this policy, please refer to the Schedule of Benefits and Orthodontic Expense Benefits provision found on 9260)

10. for which the Insured person is entitled to benefits under any workmen’s compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit

11. for charges which the Insured person is not liable or which would not have been made had no insurance been in force

12. for services that are not required for necessary care and treatment or are not within the generally accepted parameters of care

13. because of war or any act of war, declared or not

Vision Service Plan - Eye Care Limitations and Exclusions:

Covered Expenses will not include and benefits will not be payable for expenses incurred for: 

1. vision examinations more than the frequency as indicated on the plan summary page

2. lenses more than the frequency as indicated on the plan summary page

3. frames more than the frequency as indicated on the plan summary page

4. contact lenses more than once in any twelve month period.  When chosen, contact lenses shall be in lieu of any other lens or frame benefit during the twelve month period.  When lenses and frames are chosen, expenses for contact lenses are not Covered Expenses during the twelve month period

5. examinations performed or frames or lenses ordered before the member was covered under the eye care expense benefits.

6. subject to extension of benefits, any examination performed or frame or lens ordered after the member's coverage under the eye care expense benefits ceases

7. sub-normal eye care aids; orthoptic or eye care training or any associated testing.

8. non-prescription lenses.

9. replacement or repair of lost or broken lenses or frames except at normal intervals.

10. any eye examination or corrective eyewear required by an employer as a condition of employment.

11. medical or surgical treatment of the eyes.

12. any service or supply not shown on the Schedule of Eye Care Procedures.

13. coated lenses; oversize lenses (exceeding 71 mm); photo-gray lenses; polished edges; UV-400 coating and facets, and tints other than solid.