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Plan Type PPO
Coinsurance None
Deductible $25 individual
Annual Maximum Benefit $500
Office Visit
Find Dentists
No charge
Primary Benefits
Teeth Cleanings No charge
Restorative Dentistry/Fillings You pay $37 (One-surface Composite Filling)
Oral Surgery Not Covered
Extractions Not Covered
X-Rays No Charge. Deductible Waived
Crowns Not Covered
Root Canals Not Covered
Periodontics Not Covered
Dentures Not Covered
Topical Fluoride No Charge
Sealant No Charge. Deductible Waived
Bridges Not Covered
Endodontics Not Covered
Additional Information
A.M. Best Rating A as of 04/17/2014
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.