Enhanced Dental PPO 25/500

Primary Benefits
Plan Type	DPPO
Coinsurance	20% - 50%
Deductible	$25 per member/$75 per family
Annual Maximum Benefit	$500
Office Visit Find Dentists	No Charge
Teeth Cleanings	No Charge
Restorative Dentistry/Fillings	20% coinsurance after deductible
Oral Surgery	20% coinsurance after deductible
Extractions	20% coinsurance after deductible
X-Rays	No Charge
Crowns	50% coinsurance after deductible
Root Canals	50% coinsurance after deductible
Periodontics	50% coinsurance after deductible
Dentures	50% coinsurance after deductible
Topical Fluoride	No Charge
Sealant	No Charge
Bridges	50% coinsurance after deductible
Endodontics	50% coinsurance after deductible
Additional Information
A.M. Best Rating	A as of 08/15/2018
Electronic Signature for Application Available	Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

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.

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