Monthly Rates |
|
|---|---|
Value |
|
| Single Only | $24.04 |
| Insured & One (Spouse or Child) | $44.48 |
| Insured & 2 or more | $66.08 |
Standard |
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| Single Only | $34.36 |
| Insured & One (Spouse or Child) | $63.16 |
| Insured & 2 or more | $92.12 |
Royal |
|
| Single Only | $43.76 |
| Insured & One (Spouse or Child) | $80.48 |
| Insured & 2 or more | $118.08 |
100/70/50 |
|
Region 1— AL, AR, AZ, KS, KY, LA, MO, MS, NE, ND, OH, OK, SC, SD, TN, WV |
|
| Single Only | $41.96 |
| Insured & One (Spouse or Child) | $89.24 |
| Insured & 2 or more | $154.40 | Region 2— DE, FL, GA, IA, IL, IN, NC, NM, PA, TX, VA, WY |
| Single Only | $45.84 |
| Insured & One (Spouse or Child) | $97.40 |
| Insured & 2 or more | $168.12 | Region 3— ID, MD, ME, MI, MN, MT, UT, VT, WI |
| Single Only | $52.54 |
| Insured & One (Spouse or Child) | $111.46 |
| Insured & 2 or more | $192.70 | Region 4— CO, MA, NJ, NV, OR, RI |
| Single Only | $59.68 |
| Insured & One (Spouse or Child) | $126.60 |
| Insured & 2 or more | $218.96 | Region 5— AK, CA, CT, DC, HI, NY, WA |
| Single Only | $65.32 |
| Insured & One (Spouse or Child) | $138.64 |
| Insured & 2 or more | $240.36 |
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| Dental Benefits | ||||||||||||
| Benefit Options | Value | Standard | Royal | 100/70/50 | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Deductible—Calendar Year Per Person | $25 on Basic and Major Services Only | $25 on Basic and Major Services Only | $25 on Basic and Major Services Only | $25 on Basic and Major Services Only | ||||||||
| Waiting Periods | None | None | None | 24 month for orthodontia only | ||||||||
| Plan Maximum | $1,200 | $1,200 | $1,200 | $1,500 | ||||||||
| Dental Rewards | If within a calendar year an individual goes to the dentist at least once and never uses more than $750 of the plan maximum, the plan maximum will increase an additional $250 for the next year. This will continue to build up to a maximum of an additional $1,000 carryover as long as the two provisions are met. If the member does not submit a covered claim during the calendar year, they will lose their accumulated carryover benefits and will not earn any for that year. If the member exceeds the $750 threshold, they will not lose any accumulated carryover, however they will not earn any additional carryover for that year. | |||||||||||
| Providers | Benefits are payable to any licensed dental provider. But if you use one of our more than 425,000 access points nationwide, you could receive even greater savings. Click Here to find a listing. | |||||||||||
| Preventive Services | Schedule* | Schedule* | Schedule* | 100% | ||||||||
| Basic Services | Schedule* | Schedule* | Schedule* | 70% | ||||||||
| Major Services | Schedule* | Schedule* | Schedule* | 50% | ||||||||
| Orthodontia Services | Not Covered | Not Covered | Not Covered | 50% coverage after a 24 month waiting period with a $2,500 Lifetime Maximum per person (no coverage for adult Ortho) | ||||||||
| Eye Care Benefits | ||||||||||||
| Eye Care Benefit for Exams, Frames, Lenses and Contact Lenses |
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| Laser Vision Correction Coverage Benefit |
If an Insured undergoes or receives a covered procedure rendered by a provider, the policy will pay benefits as stated below. Benefit amount payable for covered procedures per insured person. Lifetime maximum benefit per eye for covered procedures, we will pay the lesser of the provider’s actual charge or the following benefit amount that corresponds to the benefit period in which the covered procedure was performed:
|
N/A | ||||||||||
| Hearing Benefit | ||||||||||||
| SoundCare Hearing Health Benefits |
For questions on this benefit or to locate an EPIC provider, please call 877-359-8346
|
N/A | ||||||||||
Limitations Covered Expenses will not include and no benefit will be payable for expenses incurred:
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| HOW MUCH THE DENTAL INSURANCE WILL PAY FOR THE VALUE, STANDARD AND ROYAL OPTIONS | |||
| *Sample Schedule of Benefits | Value | Standard | Royal |
|---|---|---|---|
| Preventive - NO DEDUCTIBLE | |||
| Two evaluations per calendar year | $13 each | $16 each | $20 each |
| Two cleanings per calendar year—Adult | $33 each | $40 each | $50 each |
| Two cleanings per calendar year—Child | $22 each | $27 each | $34 each |
| Fluoride for Children (Under age 19) |
$13 | $15 | $19 |
| Basic | |||
| X-rays—complete series (including bitewings) |
$40 | $48 | $60 |
| Bitewings—two films (Twice in a Benefit Period) | $15 | $18 | $22 |
| Amalgam restoration (silver fillings)—one surface, primary or permanent | $35 | $42 | $53 |
| Extraction—Erupted tooth or exposed root (elevation and/or forceps removal) | $40 | $48 | $60 |
| Surgical removal of tooth (completely bony) | $83 | $100 | $125 |
| Deep sedation/general anesthesia | $116 | $140 | $175 |
| Major | |||
| Maxillary partial denture—resin base | $248 | $300 | $375 |
| Denture repair-Repair Broke Base | $30 | $36 | $45 |
| Endodontics—root canal, anterior | $132 | $160 | $200 |
| Periodontal scaling and root planing, four or more teeth. Each quadrant is eligible for consideration once in a 2 year period | $43 | $52 | $65 |
| Crown—full cast noble metal | $185 | $224 | $280 |
| Crown repair | $50 | $60 | $75 |
| Pontics—porcelain fused to noble metal | $185 | $224 | $280 |