|Annual Maximum Benefit||None|
|No charge - Comprehensive or Periodic|
|Teeth Cleanings||No charge;
once every six months
|Restorative Dentistry/Fillings||One Surface Amalgam Anterior Resin $80 Copay;
|Oral Surgery||$60-$4200 Copay|
|X-Rays||No Charge for 7 different X-rays if in network|
|Crowns||$247-$500 Copay (varies)- Additional charges for lab fees may apply|
|Root Canals||$425-$675Copay (varies)|
|Dentures||$625 Upper/$695 Lower Copay- Additional charges for lab fees may apply|
|Topical Fluoride||No charge|
|Bridges||$440-$495 (plus lab fee) Copay|
|A.M. Best Rating||N/A as of 03/21/2011|
|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.