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|Coinsurance||Preventive and Diagnostic:0%; Basic: 20%; Major: 50%|
|Deductible||$50 individual / $150 family|
|Annual Maximum Benefit||$1,000|
|Preventive and Diagnostic:0%; Basic: 20%; Major: 50%|
|Teeth Cleanings||No Charge (limited to 2 per adult/2 per child per year)|
|Restorative Dentistry/Fillings||20% after deductible - 6 months waiting period|
|Oral Surgery||50% after deductible - 12 months waiting period|
|Extractions||50% after deductible - 12 months waiting period|
|X-Rays||No Charge - No waiting period|
|Crowns||50% after deductible - 12 months waiting period|
|Root Canals||50% after deductible - 12 months waiting period|
|Periodontics||50% after deductible - 12 months waiting period|
|Dentures||50% after deductible - 12 months waiting period|
|Topical Fluoride||Cleaning with fluoride (limited to 2 per child per year): No Charge|
|Endodontics||50% after deductible for covered services - 12 months waiting period|
|A.M. Best Rating||A as of 04/25/2013|
|Electronic Signature for Application Available||Yes|
|Details and documents about this plan|
|View Plan Brochure Exclusions and Limitations|
IMPORTANT NOTICES AND DISCLAIMERS
- THE BENEFITS MATRIX IS A SUMMARY FOR INFORMATIONAL PURPOSES ONLY. REVIEW THE EVIDENCE OF COVERAGE AND INSURANCE POLICY (PLAN CONTRACT) FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS, LIMITATIONS, AND EXCLUSIONS. ONLY THE TERMS AND CONDITIONS OF COVERAGE BENEFITS LISTED IN THE POLICY ARE BINDING.
- The benefits listed may be contingent on your use of physicians, hospitals, dentists and services within the specific insurance company's provider network.
- The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
- The quotes or rates shown above are estimates only. Your premium is subject to change based on your medical history (pursuant to state law of residence), the underwriting practices of the insurance company, the optional benefits you selected, if any, and other relevant factors, such as changes in rates which take effect before your requested effective date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.