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Plan Type PPO
Coinsurance Preventive:0%
Deductible $50/$150
Annual Maximum Benefit $1,000
Office Visit
Find Dentists
No Charge (No waiting period)
Primary Benefits
Teeth Cleanings No Charge (No waiting period)
Restorative Dentistry/Fillings Fee Schedule (3 month waiting period)
Oral Surgery Fee Schedule (12 month waiting period)
Extractions Fee Schedule (12 month waiting period)
X-Rays No Charge (No waiting period)
Crowns Stainless Steel Crown:Fee Schedule(12 month waiting period)
Resin/Porcelain Crown:Fee Schedule(12 month waiting period)
Root Canals Fee Schedule (12 month waiting period)
Periodontics Fee Schedule (12 month waiting period)
Dentures Fee Schedule (12 month waiting period)
Topical Fluoride No Charge (No waiting period)
Sealant No Charge (No waiting period)
Bridges Fee Schedule (12 month waiting period)
Endodontics Fee Schedule (12 month waiting period)
Additional Information
A.M. Best Rating Au as of 06/24/2015
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.
  • Drug Savings amounts shown are only estimates — your costs and savings can differ. Check your plan information for accuracy. See details.