Dental Insurance Plan
Economy, Value, Standard and Royal Plans Benefit Outline—Over 400 Covered Procedures

Deductible — $25 Per Calendar Year Per Person Deductible for Basic and Major Services ONLY!

Elimination Period — No waiting period on any covered procedures

Plan Maximum — $1,200 Per Calendar Year Per Person
(This is a combined maximum for dental and vision benefits)

Dental Rewards — If within a calendar year an individual goes to the dentist at least once and never uses more than $750 of the plan maximum, the plan maximum will increase an additional $250 for the next year. This will continue to build up to a maximum total of $2,000 as long as the two provisions are met. If the two provisions are not met in one calendar year the plan maximum will go back to $1,200 for the next year.

Make sure you add up the benefits for each procedure performed to get the total benefit amount for one dental visit!

Sample Schedule of Benefits
How much the insurance will pay		 Economy Value Standard Royal
Preventive - NO DEDUCTIBLE
Two evaluations per calendar year $11 each $13 each $16 each $20 each
Two cleanings per calendar year—Adult $28 each $33 each $40 each $50 each
Two cleanings per calendar year—Child $19 each $22 each $34 each $27 each
Fluoride for Children (Under age 19)
 $11 $13 $15 $19
Basic
X-rays—complete series (including bitewings)
 $34 $40 $48 $60
Bitewings—two films (Twice in a Benefit Period) $12 $15 $18 $22
Amalgam restoration (silver fillings)—one surface, primary or permanent $29 $35 $42 $53
Extraction—Erupted tooth or exposed root (elevation and/or forceps removal) $34 $40 $48 $60
Surgical removal of tooth (completely bony) $70 $83 $100 $125
Deep sedation/general anesthesia $98 $116 $140 $175
Major
Maxillary partial denture—resin base $210 $248 $300 $375
Denture repair-Repair Broken Base $25 $30 $36 $45
Endodontics—root canal, anterior $112 $132 $160 $200
Periodontal scaling and root planning, four or more teeth. Each quadrant is eligible for consideration once in a 2 year period $36 $43 $52 $65
Crown—full cast noble metal $157 $185 $224 $280
Crown repair $42 $50 $60 $75
Pontics—porcelain fused to noble metal $157 $185 $224 $280

Vision Insurance Plan

  • $0 Deductible
  • 100% up to a maximum of $150 which is deducted out of the total $1,200 maximum allowed for the dental/eye care plan.
  • You can go to any licensed eye care provider but you will receive additional savings if you go to an Eye Med provider

Coverage for:

  • Exams - Includes case history; external examination of the eye and adnexa; ophthalmoscopic examination; determination of refracture status; binocular balance; tonometry test for glaucoma; gross visual field when indicated; summary finding; prescribing of lenses.
  • Frames
  • Lenses - Single; Bifocal; Trifocal; No line bifocal or progressive power; Lenticular
  • Contact Lenses

Laser Vision Correction

  • 1st Benefit Period - $0 per eye
  • 2nd Benefit Period - $100 per eye
  • 3rd Benefit Period - $250 per eye
  • 4th Benefit Period - $500 per eye

For More Information on Benefits
Call 877-817-4805

Limitations

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

  1. 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.
  2. for any treatment which is for cosmetic purposes. Facings on crowns or pontics behind the second bicuspid are considered cosmetic.
  3. 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.
  4. 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.
  5. for any procedure started before a person becomes insured.
  6. 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.
  7. to replace lost or stolen appliances.
  8. 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)
  9. for any procedure which is not shown on the List of Dental Procedures provided with your Certificate of Insurance.
  10. for education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control.
  11. for the completion of claim forms.
  12. for orthodontic treatment.
  13. because of any injury arising out of, or in the course of, work for wage or profit.
  14. 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.
  15. for charges for which a person is not liable or which would not have been made had no insurance been in force.
  16. for services which are not recommended by a physician or which are not required for necessary care and treatment.
  17. because of war or any act of war, declared or not.
  18. by a person if payment is not legal where the person is living when expenses are incurred.
  19. 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.
  20. 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.

*Please refer to policy certificate for complete details on all benefits, frequencies and plan limitations.