Specialty DuoSM Plan Dental + Vision
|Annual Maximum Benefit||$1,000|
|Teeth Cleanings||No Charge|
|Restorative Dentistry/Fillings||$37 per tooth after deductible|
|Oral Surgery||$263 per quadrant after deductible|
|Extractions||$40 per tooth after deductible|
|Crowns||$265 each crown after deductible|
|Root Canals||Anterior root canal: $156 per tooth after deductible; Molar root canal: $234 per tooth after deductible|
|Periodontics||$65 per quadrant after deductible|
|Dentures||$388 per denture after deductible|
|Topical Fluoride||No Charge|
|Sealant||No Charge, covered to age 15|
|Bridges||$293 each tooth replaced after deductible|
|Endodontics||Anterior root canal: $156 per tooth after deductible; Molar root canal: $234 per tooth after deductible|
|A.M. Best Rating||A as of 09/06/2019|
|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.