DENTAL INSURANCE
AMIkids offers dental coverage through Blue Cross Blue Shield (BCBS). Both plan options are Dental PPOs, which allow you to use in- network or out-of-network benefits. If out-of-network dentists are used, you will be responsible for the balance billed amount (the difference between BCBS’ allowed amount and what the dentist charges). The chart below provides a brief overview of the plans. To find in-network providers visit www.MyHealthToolkitFL.com and click on “Find a Dentist” within the right column. If the below illustration of benefits conflicts in any way with the plan description, then the plan description shall prevail.
Base PPO Plan
Premium PPO Plan
In-Network
Deductible (applies to Basic & Major services)
$50
$50
Individual
$150
$150
Family
Annual Maximum (per covered member)
$1,000
$1,500
Preventive Services
Covered in full
Covered in full
Exams, Cleanings, & Fluoride
Basic Services
Fillings, Simple Extractions, Perio & Endo (other than those listed below)
You pay 20% after deductible
You pay 20% after deductible
Major Services
Crowns, Bridges, Surgical Extractions, Root Canal, Dentures, Osseus Surgery & Endo Molars
You pay 50% after deductible
You pay 50% after deductible
Orthodontia (child 18 and under only)
40% $2,000 lifetime maximum per person
None
Out-of Network 1
Basis of Payment
90% Usual & Customary Charges
Deductible (applies to Basic & Major services) Individual / Family
$50 / $150
$50 / $150
Annual Maximum (per covered member)
$1,000
$1,500
Services Preventive Basic Major
Covered in full You pay 20% after deductible You pay 50% after deductible
Covered in full You pay 20% after deductible You pay 50% after deductible
Orthodontia (child 18 and under only)
40% $2,000 lifetime maximum per person
None
1 Subject to balance billing . Please refer to your plan document for specific details.
Cost for Coverage Amounts shown are per pay check ( 24 payments/year )
Base PPO
Premium PPO
Employee Only
EE
$ 4.68
$ 9.35
Employee + Spouse
ES
$12.13
$21.56
Employee + Child(ren)
EC
$14.78
$29.52
Employee + Family
FAM
$24.51
$45.26
12
Made with FlippingBook Online document