PLAN BENEFITS 1
INDIVIDUAL MONTHLY PREMIUM Age $1,000 $1,500 $3,000 $5,000 18 - 39 $30.24 $39.98 $48.15 $60.64 40 - 54 $32.74 $42.40 $52.23 $65.56 55 - 64 $35.07 $45.98 $59.56 $73.72 65 - 74 $37.57 $49.65 $64.39 $78.97 75 - 85 $43.15 $57.06 $74.05 $88.63 FAMILY MONTHLY PREMIUM * Age $1,000 $1,500 $3,000 $5,000 18 - 39 $96.79 $127.70 $154.19 $199.09 40 - 54 $101.63 $132.61 $159.85 $208.92 55 - 64 $106.54 $139.86 $172.60 $225.24 65 - 74 $111.37 $147.11 $190.59 $235.74 75 - 85 $128.03 $169.18 $219.50 $255.06 CHILD MONTHLY PREMIUM * Age $1,000 $1,500 $3,000 $5,000 3 - 17 $22.74 $29.99 $36.15 $48.65 * Family rates include up to three children. Additional children are charged the age 3 - 17 rate per person. * Individual and (1) child will be charged an individual + child rate. Premiums are subject to change. Premium rates based on $1,000, $1,500, $3,000 or $5,000 Policy Year Maximum. Use the age of the oldest applicant. Benefit exclusions and limitations apply.
Eligibility
Anyone age 18 - 85 $1,000, $1,500, $3,000 o $5,000 (choose one) $100 per person
Policy Year Maximum Benefit
Policy Year Deductible
Dental Coverage Preventive Services Semi-Annual exams, cleaning and x-rays
Year 1 - 60% Year 2 - 70% Year 3 and thereafter - 80%
Waiting Period
None
Year 1 - 60% Year 2 - 70% Year 3 and thereafter - 80%
Basic Services Including x-ray, fillings and extractions (other than “full mouth”)
Waiting Period
None
Major Services Including bridges, crowns, full dentures or partials, full mouth extractions, and root canals
Year 1 - 0% Year 2 - 70% Year 3 and thereafter - 80%
Waiting Period
12 months
Vision Coverage Basic eye exam, eye refraction, including the cost of eye glasses or contact lenses
Year 1 - 60% Year 2 - 70% Year 3 and thereafter - 80% 6 months on eyeglasses and contact lenses Year 1 - 60% Year 2 - 70% Year 3 and thereafter - 80% 12 months new hearing aids and existing hearing aid repairs
Waiting Period
Hearing Coverage
Exam, hearing aid and necessary repairs or supplies
Waiting Period
Policy Form Numbers: AK7016, AK7016-ID, AK7016-LA, AK7016-MT, AK7016-OK, AK7016-TX (including state variations)
1 Refer to your policy for a complete description of limitations and exclusions.
Underwritten by: ManhattanLife Insurance and Annuity Company 10777 Northwest Freeway, Houston, TX 77092 Toll Free Telephone: 800-669-9030
This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Dental, Vision and Hearing product at disclosure.manhattanlife.com . Please review this information before applying for coverage. The amounts of benefits provided depend on the plan selected. Premiums will vary according to the selection made.
Made with FlippingBook Learn more on our blog