Plan Benefits
Issue Age: Ages 18 - 99 Policy Year Maximum Benefit: $1,000, $1,500, $3,000, or $5,000 Policy Year Deductible: $0 or $100 per person (does not apply to Preventative Services) In-Network Out-of-Network
Preventive Services • Dental Exams; 2 per year • Cleanings; 2 per year
100% of contracted rate
• Bitewing X-Rays; 2 per year • Fluoride treatment is for age 16 and under; 2 visits per year
80% of UCR
Waiting Period
None
Basic Services • Limited Oral Evaluation • Diagnostic Consultation
• Basic Restorative Service
65% of contracted rate 1st yr. 80% thereafter
• Filling • Emergency Palliative Treatment • Basic Oral Surgery • Panoramic X-Ray • Periodontal Service • Periapical X-Ray • Non-Surgical Extraction • Periodontal Non-Surgical Service
65% of UCR 1st yr. 80% thereafter
Waiting Period
None
Major Services • Major Restorative Service
20% of contracted rate 1st yr. 50% thereafter
• Periodontal Service • Prosthodontic Service
20% of UCR 1st yr. 50% thereafter
• Inlay/Onlay/Crown • Endodontic Service
• Implants (Lifetime maximum $1,500)
Waiting Period
None
20% of contracted rate 1st yr. 50% thereafter
20% of UCR 1st yr. 50% thereafter
All Other Medically Necessary Services (services not listed above)
Waiting Period
None
Orthodontia • Straightening of Teeth (for all ages) • Lifetime Max $1,500
Year 1 - N/A Year 2+ - 50%
N/A
Waiting Period
12 Months
1st year: 60% of UCR 2nd year: 70% of UCR Thereafter: 80% of UCR 1 per year $200 maximum per year
Vision Services • Eye Exam • Single Lenses • Trifocal Lenses • Eyeglass Frame 3
• Refraction
• Bifocal Lenses
• Progressive Lenses
• Contact Lenses
• Anti-Reflective Lenses • Polycarbonate Lenses • Contact Lens Fitting Fee
$45; 1 per year $40; 1 per year $15; 1 per year
Waiting Period
6 Months on Eyeglass Frames
Hearing Services • Hearing Exam
$750 maximum (per ear, per year)
• Hearing Aid and Necessary Repairs or Supplies 1
12 Months for Hearing Aid and Necessary Repairs or Supplies UCR - Usual, Customary and Reasonable (See back page for more details)
Waiting Period
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