Plan Benefit

Calendar-year Deductible: $0

Preventive Services 100% covered

Basic Services Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Major Services Coinsurance Levels:

• Year 1: 0%
• Year 2+: 60%

Vision Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Vision Benefit:

• Vision savings maximum during any two policy years: $200. This benefit will count toward the policy’s annual maximum benefit amount.

Hearing Coinsurance Levels:

• Year 1: 0%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Hearing Benefit:

• Hearing savings maximum during any one policy year: $500. This benefit will count toward the policy’s annual maximum benefit amount.

Plan Benefit

Calendar-year Deductible: $0

Preventive and Basic Services Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Major Services Coinsurance Levels:

• Year 1: 0%
• Year 2+: 60%

Vision Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Vision Benefit:

• Vision savings maximum during any two policy years: $200. This benefit will count toward the policy’s annual maximum benefit amount.

Hearing Coinsurance Levels:

• Year 1: 0%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Hearing Benefit:

• Hearing savings maximum during any one policy year: $500. This benefit will count toward the policy’s annual maximum benefit amount.

Plan Benefit

Calendar-year Deductible: $0

Preventive and Basic Services Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Major Services Coinsurance Levels:

• Year 1: 0%
• Year 2+: 60%

Vision Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Vision Benefit:

• Vision savings maximum during any two policy years: $200. This benefit will count toward the policy’s annual maximum benefit amount.

Hearing Coinsurance Levels:

• Year 1: 0%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Hearing Benefit:

• Hearing savings maximum during any one policy year: $500. This benefit will count toward the policy’s annual maximum benefit amount.

Plan Benefit

Calendar-year Deductible: $0

Preventive Services 100% covered

Basic Services Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Major Services Coinsurance Levels:

• Year 1: 0%
• Year 2+: 60%

Vision Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Vision Benefit:

• Vision savings maximum during any two policy years: $200. This benefit will count toward the policy’s annual maximum benefit amount.

Hearing Coinsurance Levels:

• Year 1: 0%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Hearing Benefit:

• Hearing savings maximum during any one policy year: $500. This benefit will count toward the policy’s annual maximum benefit amount.

Plan Benefit

Calendar-year Deductible: $0

Preventive Services 100% covered

Basic Services Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Major Services Coinsurance Levels:

• Year 1: 0%
• Year 2+: 60%

Vision Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Vision Benefit:

• Vision savings maximum during any two policy years: $200. This benefit will count toward the policy’s annual maximum benefit amount.

Hearing Coinsurance Levels:

• Year 1: 0%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Hearing Benefit:

• Hearing savings maximum during any one policy year: $500. This benefit will count toward the policy’s annual maximum benefit amount.

Plan Benefit

Calendar-year Deductible: $0

Preventive Services 100% covered

Basic Services Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Major Services Coinsurance Levels:

• Year 1: 0%
• Year 2+: 60%

Vision Coinsurance Levels:

• Year 1: 60%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Vision Benefit:

• Vision savings maximum during any two policy years: $200. This benefit will count toward the policy’s annual maximum benefit amount.

Hearing Coinsurance Levels:

• Year 1: 0%
• Year 2: 70%
• Year 3: 80%
• Year 4+: 90%

Hearing Benefit:

• Hearing savings maximum during any one policy year: $500. This benefit will count toward the policy’s annual maximum benefit amount.

Plan Benefit

Copay: None

Deductible: $50 (Basic and Major benefit year deductible is combined per person with a maximum of 3 deductibles per family)

Preventive (Type 1): Plan pays 100% on Day 1. Plan pays 100% after year 1.

• Exams (2 per year)
• Cleanings (2 per year)
• Bitewing X-rays

Basic (Type 2): Plan pays 80% on Day 1. Plan pays 90% after year 1.

• Fillings
• Simple Extractions

Major (Type 3): Plan pays 20% on Day 1. Plan pays 50% after year 1.

• Crowns
• Root Canals
• Oral Surgery
• Dentures
• Bridges
• Panoramic X-rays
• Implants
• Periodontics

Other Benefits

• Increasing Maximum: The annual maximum benefit day one is $2500. After year one the maximum increases to $3000. Insurance covers a maximum amount per person per benefit period for Preventive Basic and Major services combined.
• Hearing Benefit: Benefits are available for hearing exams and hearing aids. Each benefit period you receive up to $75 for eligible hearing exams. The plan pays 50% of the hearing aid cost up to the maximum benefit. The maximum benefit is $200 day 1/$300 after year 1/$400 after year 2. Five years after using your hearing aid coverage you are re-eligible for the benefit at the top level. A reduced benefit is available after three years if your current hearing aids can no longer correct your hearing. All benefits assume no break in coverage.

• Credit for prior coverage (CPC) is available for those replacing a fully insured dental plan from another carrier. CPC is not available if the prior plan was a DHMO discount or schedule plan. The gap in coverage must be no more than two months from the new plan effective date and prior coverage should have been in effect for at least 12 months. By providing the policy number and company name policyholders may receive increased benefit coverage day one for Preventive Basic and Major dental services. Orthodontia waiting periods cannot be waived. CPC is not available in all states.

Plan Benefit

Copay: None

Deductible: $50 (Basic and Major benefit year deductible is combined per person with a maximum of 3 deductibles per family)

Preventive (Type 1): Plan pays 100% on Day 1. Plan pays 100% after year 1.

• Exams (2 per year)
• Cleanings (2 per year)
• Fluoride (under age 16)
• Sealants (under age 16)
• Bitewing X-rays

Basic (Type 2): Plan pays 65% on Day 1. Plan pays 80% after year 1.

• Fillings
• Simple Extractions

Major (Type 3): Plan pays 20% on Day 1. Plan pays 50% after year 1.

• Crowns
• Root Canals
• Teeth Whitening
• Oral Surgery
• Dentures
• Bridges
• Panoramic X-rays
• Implants
• Periodontics

Child Orthodontia: Plan pays 15% on Day 1 and 50% after year 1

• Straighten teeth (under age 19)
• Close gap between teeth (under age 19)
• Correct problems with bite (under age 19)
• Alignment of teeth and jaw (under age 19)
• Lifetime maximum $1000 per child

• Credit for prior coverage (CPC) is available for those replacing a fully insured dental plan from another carrier. CPC is not available if the prior plan was a DHMO discount or schedule plan. The gap in coverage must be no more than two months from the new plan effective date and prior coverage should have been in effect for at least 12 months. By providing the policy number and company name policyholders may receive increased benefit coverage day one for Preventive Basic and Major dental services. Orthodontia waiting periods cannot be waived. CPC is not available in all states.

Plan Benefit

Copay: None

Deductible: $50 (Basic and Major benefit year deductible is combined per person with a maximum of 3 deductibles per family)

Preventive (Type 1): Plan pays 100% on Day 1. Plan pays 100% after year 1.

• Exams (2 per year)
• Cleanings (2 per year)

Basic (Type 2): Plan pays 50% on Day 1. Plan pays 80% after year 1.

• Fillings
• Fluoride (under age 16)
• Sealants (under age 16)
• Bitewing X-rays

Major (Type 3): Plan pays 10% on Day 1. Plan pays 20% after year 1.

• Crowns
• Root Canals
• Oral Surgery
• Dentures
• Bridges
• Panoramic X-rays
• Periodontics

• Credit for prior coverage (CPC) is available for those replacing a fully insured dental plan from another carrier. CPC is not available if the prior plan was a DHMO discount or schedule plan. The gap in coverage must be no more than two months from the new plan effective date and prior coverage should have been in effect for at least 12 months. By providing the policy number and company name policyholders may receive increased benefit coverage day one for Preventive Basic and Major dental services. Orthodontia waiting periods cannot be waived. CPC is not available in all states.

Plan Benefit

Per Visit Deductible: $25

Type I - Preventive Services Coinsurance Levels:

• 100% Covered

Type I - Preventive Services Benefit:

• Routine Exams (1 per 6 months); Prophylaxis (cleanings - 1 per 6 months); Emergency exams for dental pain (minor procedures); Fluoride treatments for dependent children under age 19 (1 per 12 months); Bitewing X-rays (1 per 6 months)

Type II - Basic Services Coinsurance Levels:

• 80% Covered

Type II - Basic Services Benefit:

• Simple restorative services (fillings); Simple extractions; Palliative treatment for dental pain (local anesthesia); Sealants for children ages 6-15 (1 per tooth); Periapical X-rays; Full mouth or panorex X-rays (1 per 36 months)

Type III - Major Services Coinsurance Levels:

• Year 1: 0%
• Year 2+: 50%

Type III - Major Services Benefit:

• Major restorative services (crowns and inlays); Prosthetics (bridges and dentures); Replacement of prosthodontics-dentures-crowns-and inlays; Denture relines; Space maintainers; General anesthesia (for services dentally necessary); Endodontics/root canal therapy; Periodontics; Oral surgery; Implants

Plan Benefit

Per Visit Deductible: $25

Type I - Preventive Services Coinsurance Levels:

• 100% Covered

Type I - Preventive Services Benefit:

• Routine Exams (1 per 6 months); Prophylaxis (cleanings - 1 per 6 months); Emergency exams for dental pain (minor procedures); Fluoride treatments for dependent children under age 19 (1 per 12 months); Bitewing X-rays (1 per 6 months)

Type II - Basic Services Coinsurance Levels:

• 80% Covered

Type II - Basic Services Benefit:

• Simple restorative services (fillings); Simple extractions; Palliative treatment for dental pain (local anesthesia); Sealants for children ages 6-15 (1 per tooth); Periapical X-rays; Full mouth or panorex X-rays (1 per 36 months)

Type III - Major Services Coinsurance Levels:

• Year 1: 0%
• Year 2+: 50%

Type III - Major Services Benefit:

• Major restorative services (crowns and inlays); Prosthetics (bridges and dentures); Replacement of prosthodontics-dentures-crowns-and inlays; Denture relines; Space maintainers; General anesthesia (for services dentally necessary); Endodontics/root canal therapy; Periodontics; Oral surgery; Implants

Plan Benefit

Per Visit Deductible: $25

Type I - Preventive Services Coinsurance Levels:

• 100% Covered

Type I - Preventive Services Benefit:

• Routine Exams (1 per 6 months); Prophylaxis (cleanings - 1 per 6 months); Emergency exams for dental pain (minor procedures); Fluoride treatments for dependent children under age 19 (1 per 12 months); Bitewing X-rays (1 per 6 months)

Type II - Basic Services Coinsurance Levels:

• 80% Covered

Type II - Basic Services Benefit:

• Simple restorative services (fillings); Simple extractions; Palliative treatment for dental pain (local anesthesia); Sealants for children ages 6-15 (1 per tooth); Periapical X-rays; Full mouth or panorex X-rays (1 per 36 months)

Type III - Major Services Coinsurance Levels:

• Year 1: 0%
• Year 2+: 50%

Type III - Major Services Benefit:

• Major restorative services (crowns and inlays); Prosthetics (bridges and dentures); Replacement of prosthodontics-dentures-crowns-and inlays; Denture relines; Space maintainers; General anesthesia (for services dentally necessary); Endodontics/root canal therapy; Periodontics; Oral surgery; Implants

Plan Benefit

Calendar-year Deductible: $50

Diagnostic and Preventive Services Coinsurance Levels:

• 100% Covered

Diagnostic and Preventive Services Benefit:

• No Waiting Period
• Routine exams
• Cleanings
• Sealants
• Bitewing x-rays
• Diagnostic Benefits - See Brochure

Basic Services Coinsurance Levels:

• Year 1: 25%; Year 2+: 50%

Basic Services Benefit:

• No Waiting Period
• Minor Restorative Services - Fillings
• Extractions
• X-rays

Major Services Coinsurance Levels:

• Year 1: 25%; Year 2+: 50%

Major Services Benefit:

• No Waiting Period
• Implants - NA
• Endodontics - See Brochure
• Periodontics - See Brochure
• Prosthodontics - See Brochure
• Routine Dental Services - No Charge
• Dentures - Year 1: 25%; Year 2+: 50%

Plan Benefit

Calendar-year Deductible: $50

Diagnostic and Preventive Services Coinsurance Levels:

• 100% Covered

Diagnostic and Preventive Services Benefit:

• No Waiting Period
• Routine exams
• Cleanings
• Sealants
• Bitewing x-rays
• Diagnostic Benefits - See Brochure

Basic Services Coinsurance Levels:

• Year 1: 50%; Year 2+: 100%

Basic Services Benefit:

• No Waiting Period
• Minor Restorative Services - Fillings
• Extractions
• X-rays

Major Services Coinsurance Levels:

• Year 1: 25%; Year 2+: 50%

Major Services Benefit:

• No Waiting Period
• Implants - Year 1: 25%; Year 2+: 50%
• Endodontics - See Brochure
• Periodontics - See Brochure
• Prosthodontics - See Brochure
• Routine Dental Services - No Charge
• Dentures - Year 1: 25%; Year 2+: 50%

Plan Benefit

Calendar-year Deductible: $50

Diagnostic and Preventive Services Coinsurance Levels:

• 100% Covered

Diagnostic and Preventive Services Benefit:

• No Waiting Period
• Routine exams
• Cleanings
• Sealants
• Bitewing x-rays
• Diagnostic Benefits - See Brochure

Basic Services Coinsurance Levels:

• Year 1: 25%; Year 2+: 50%

Basic Services Benefit:

• No Waiting Period
• Minor Restorative Services - Fillings
• Extractions
• X-rays

Plan Benefit

Calendar-year Deductible: $50

Diagnostic and Preventive Services Coinsurance Levels:

• 100% Covered

Diagnostic and Preventive Services Benefit:

• No Deductible. No Waiting Period.

Basic Services Coinsurance Levels:

• 80% Covered

Basic Services Benefit:

• No Waiting Period.

Major Services Coinsurance Levels:

• Year 1: 20%
• Year 2+: 50%

Major Services Benefit:

• No Waiting Period.

Plan Benefit

Calendar-year Deductible: $50

Diagnostic and Preventive Services Coinsurance Levels:

• 100% Covered

Diagnostic and Preventive Services Benefit:

• No Deductible. No Waiting Period.

Basic Services Coinsurance Levels:

• 80% Covered

Basic Services Benefit:

• No Waiting Period.

Major Services Coinsurance Levels:

• Year 1: 20%
• Year 2+: 50%

Major Services Benefit:

• No Waiting Period.

Plan Benefit

Calendar-year Deductible: $50

Diagnostic and Preventive Services Coinsurance Levels:

• 100% Covered

Diagnostic and Preventive Services Benefit:

• No Deductible. No Waiting Period.

Basic Services Coinsurance Levels:

• 80% Covered

Basic Services Benefit:

• No Waiting Period.

Major Services Coinsurance Levels:

• Year 1: 20%
• Year 2+: 50%

Major Services Benefit:

• No Waiting Period.

Plan Benefit

Calendar-year Deductible: $100

Diagnostic and Preventive Services Coinsurance Levels:

• 100% Covered

Diagnostic and Preventive Services Benefit:

• No Waiting Period.

Basic Services Coinsurance Levels:

• 50% Covered

Basic Services Benefit:

• No Waiting Period.

Major Services Coinsurance Levels:

• Year 1: 20%
• Year 2+: 50%

Major Services Benefit:

• No Waiting Period.

Plan Benefit

Calendar-year Deductible: $100

Diagnostic and Preventive Services Coinsurance Levels:

• 100% Covered

Diagnostic and Preventive Services Benefit:

• No Waiting Period.

Basic Services Coinsurance Levels:

• 50% Covered

Basic Services Benefit:

• No Waiting Period.

Major Services Coinsurance Levels:

• Year 1: 20%
• Year 2+: 50%

Major Services Benefit:

• No Waiting Period.

Plan Benefit

Calendar-year Deductible: $100

Diagnostic and Preventive Services Coinsurance Levels:

• 100% Covered

Diagnostic and Preventive Services Benefit:

• No Waiting Period.

Basic Services Coinsurance Levels:

• 50% Covered

Basic Services Benefit:

• No Waiting Period.

Major Services Coinsurance Levels:

• Year 1: 20%
• Year 2+: 50%

Major Services Benefit:

• No Waiting Period.