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Dental, Vision and Hearing Select
Plan Type Indemnity
Coinsurance Plan Pays: 1st Year 65%
2nd Year and thereafter 80%
Deductible $100 per person
Annual Maximum Benefit $3,000
Office Visit
Find Dentists 		N/A
Primary Benefits
Teeth Cleanings Plan Pays:
In-Network: 100% Contracted Rate 2 per year
Out-of-Network: 80% of UCR 2 per year
Restorative Dentistry/Fillings Plan Pays:
In-Network: 65% of contracted rate 1st year
80% thereafter
Out-of-Network: 65% of UCR 1st year
80% thereafter
Oral Surgery Plan Pays:
In-Network: 65% of contracted rate 1st year
80% thereafter
Out-of-Network: 65% of UCR 1st year
80% thereafter
Extractions Plan Pays:
For Non-Surgical Extraction: In-Network: 65% of Contracted Rate 1st year
80% thereafter
Out of Network: 65% of UCR 1st year
80% thereafter
X-Rays Plan Pays:
Bitewing X-Rays:
In-Network: 100% Contracted Rate 2 per year
Out-of-Network: 80% of UCR 2 per year
Panoramic X-Ray and Periapical X-Ray:
In-Network: 65% of contracted rate 1st yr. 80% thereafter
Out-of-Network: 65% of UCR 1st yr. 80% thereafter
Crowns Plan Pays:
In-Network: 20% of contracted rate 1st year
50% thereafter
Out-of-Network: 20% of UCR 1st year
50% thereafter
Root Canals Plan Pays:
In-Network: 20% of contracted rate 1st year
50% thereafter
Out-of-Network: 20% of UCR 1st year
50% thereafter
Note: Limited to 1 root canal treatment per tooth in any 3 policy years.
Periodontics Plan Pays:
Major Periodontics Service:
In-Network: 20% of contracted rate 1st year
50% thereafter
Out-of-Network: 20% of UCR 1st year
50% thereafter
Note: 1 periodontal surgical service per quadrant in any 3 policy years.
Dentures Plan Pays:
In-Network: 20% of contracted rate 1st year
50% thereafter
Out-of-Network: 20% of UCR 1st year
50% thereafter
Topical Fluoride Plan Pays:
In-Network: 100% Contracted Rate
Out-of-Network: 80% of UCR
Note: Fluoride treatment is for age 16 and under; 2 visits per year
Sealant Plan Pays:
In-Network: 100% Contracted Rate
Out-of-Network: 80% of UCR
Bridges Plan Pays:
In-Network: 20% of contracted rate 1st year
50% thereafter
Out-of-Network: 20% of UCR 1st year
50% thereafter
Note: 1 periodontal surgical service per quadrant in any 3 policy years.
Endodontics Plan Pays:
In-Network: 20% of contracted rate 1st year
50% thereafter
Out-of-Network: 20% of UCR 1st year
50% thereafter
Additional Information
A.M. Best Rating B++ as of 11/26/2024
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure The carrier has not provided a separate document for 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.