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Plan Type PPO
Coinsurance 30% - 80%
Deductible $50
Annual Maximum Benefit $750
Office Visit
Find Dentists
30% 1st year, 20% 2nd year, 10% 3rd year (2 visits per calendar year; deductible waived in network)
Primary Benefits
Teeth Cleanings 30% 1st year, 20% 2nd year, 10% 3rd year (2 Cleanings per calendar year; deductible waived in network)
Restorative Dentistry/Fillings 6 Month waiting period applies
60% Coinsurance after deductible for 1st year
Benefit increases to 50% 2nd year, 40% 3rd year
Oral Surgery 6 Month waiting period applies
60% Coinsurance after deductible for 1st year
Benefit increases to 50% 2nd year, 40% 3rd year
Extractions 6 Month waiting period applies
60% Coinsurance after deductible for 1st year
Benefit increases to 50% 2nd year, 40% 3rd year
X-Rays 6 Month waiting period applies
60% Coinsurance after deductible for 1st year
Benefit increases to 50% 2nd year, 40% 3rd year
Crowns 6 Month waiting period applies
80% Coinsurance after deductible for 1st year
Benefit increases to 65% 2nd year, 50% 3rd year
Root Canals 6 Month waiting period applies
80% Coinsurance after deductible for 1st year
Benefit increases to 65% 2nd year, 50% 3rd year
Periodontics 6 Month waiting period applies
80% Coinsurance after deductible for 1st year
Benefit increases to 65% 2nd year, 50% 3rd year
Dentures 6 Month waiting period applies
80% Coinsurance after deductible for 1st year
Benefit increases to 65% 2nd year, 50% 3rd year
Topical Fluoride 30% 1st year, 20% 2nd year, 10% 3rd year (limited to one treatment per calendar year to age 16; deductible waived in network)
Sealant Not covered
Bridges 6 Month waiting period applies
80% Coinsurance after deductible for 1st year
Benefit increases to 65% 2nd year, 50% 3rd year
Endodontics 6 Month waiting period applies
80% Coinsurance after deductible for 1st year
Benefit increases to 65% 2nd year, 50% 3rd year
Additional Information
A.M. Best Rating A as of 10/25/2012
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.

Carrier specific notices, disclaimers and fees

  • The plan brochure provides a brief description of some important features of your Plan. It is not the Insurance Contract, nor does it represent the Insurance Contract. A full explanation of benefits, exceptions and limitation is contained in the Certificate of Insurance under Group Policy Form LGC-8854 issued to the Voluntary Group Trust. No agent has the authority to change any benefits, to bind coverage with Symetra Life Insurance Company, or to promise a certain effective date.
  • Symetra Life Insurance Company applications must be received by the 20th of the month to have an effective date of the 1st of the following month. Benefits are insured by Symetra Life Insurance Company, Bellevue, WA 98004.
  • Symetra® and the Symetra Financial logo are registered service marks of Symetra Life Insurance Company.