Value FUSION Hybrid Plan
|Coinsurance||Varies by procedure type; see details below|
|Deductible||$25 per visit|
|Annual Maximum Benefit||$1,000Can increase to to $1,500 with Dental Rewards(see brochure for details)|
|Teeth Cleanings||Member pays 20% after deductible|
|Restorative Dentistry/Fillings||After deductible, member pays any fees above scheduled benefit (typically $45 - $55)see brochure for schedule|
|Oral Surgery||Not Covered|
|Extractions||After deductible, member pays any fees above scheduled benefit (typically $45)see brochure for schedule|
|X-Rays||Member pays 20% after deductible|
|Root Canals||Not Covered|
|Periodontics||Peridontal Maintenance OnlyAfter deductible, member pays any fees above scheduled benefit (typically $xx - $xx)see brochure for schedule|
|Topical Fluoride||Member pays 20% after deductible|
|Sealant||Member pays 20% after deductible|
|A.M. Best Rating||A as of 04/02/2020|
|Electronic Signature for Application Available||Yes|
|Details and documents about this plan|
|View Plan Brochure Exclusions and Limitations|
Important notices and disclaimers
- The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) 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.