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Plan Type PPO
Coinsurance See details
Deductible $50 per person
Annual Maximum Benefit $1,000 per person
Office Visit
Find Dentists
No charge after deductible
Primary Benefits
Teeth Cleanings No charge after deductible
Restorative Dentistry/Fillings 20% after deductible
Oral Surgery 50% after deductible
Extractions Basic Extractions: 20% Coinsurance after the deductible; 6 month waiting period;
Complex Surgical Extractions: 50% Coinsurance after the deductible. 12 month waiting period
X-Rays No charge after deductible
Crowns Not Covered
Root Canals 50% after deductible
Periodontics 50% after deductible
Dentures Not Covered
Topical Fluoride No charge after deductible
Sealant No charge after deductible
Bridges Not Covered
Endodontics 50% after deductible
Additional Information
A.M. Best Rating A as of 06/06/2014
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.