|
Covered Dental Services |
|
Class I |
|
*Diagnostic - Routine exam
once in 6 month period
*Preventative - Teeth
cleaning once in 6 month
period
*Radiography -
Bitewing x-rays once in 6
month period for dependent
children under age 18 and
once in a 12 month period
for dependent children age
18 and older, and full mouth
x-rays or panographic x-rays
when required by the Dentist
but not more than once each
36 months |
|
Class II |
|
*Restorative - Amalgam,
fillings
*Oral Surgery - Extractions
*Other - Space maintainers |
|
Class III |
|
*Endodontics - Pulpal
therapy and root canals
*Periodontics - Gum diseases
*Coverage for insured
Persons age 65 and older is
limited to a maximum
of $600 per calendar year
*Prosthetics - Crowns,
Bridges and Dentures |
|
Class IV |
|
*Orthodontia - Only
Dependent children up to age
19 |
|
Benefits Per Calendar
Year |
|
|
Per Insured |
|
Plan Maximum |
$1200.00 |
|
Benefits
for Dental, Vision and Hearing will
be combined and can not exceed the
calendar year plan maximum. |
|
|
Dental Maximum |
$1200.00 |
Orthodontia Maximum
* Lifetime maximum $1,000 |
$350.00 |
|
Vision Maximum |
$150.00 |
|
Hearing Maximum |
$300.00 |
|
Deductible
Per Calendar Year |
| |
Per Insured |
|
Dental
(Class I, Class II and Class III) |
$75.00 |
|
Vision |
$75.00 |
|
Hearing |
$75.00 |
|
Orthodontia Dental Services |
$100.00* |
|
*Lifetime |
|
|
Waiting Period |
| |
Months |
|
Diagnostic and Preventive
Dental Services
(Class I) |
0 |
|
Basic Dental Services
(Class II) |
6 |
|
Major Dental Services
(Class III) |
12 |
|
Orthodontia Dental Services
(Class IV) |
12 |
|
Vision |
0 |
|
Hearing |
0 |
|
|
|
Dental Coinsurance Amount |
|
|
Years |
|
1 |
2 |
3 |
|
Diagnostic and Preventive |
80% |
90% |
100% |
|
Basic Dental Services |
60% |
70% |
80% |
|
Major Dental Services |
0% |
40% |
50% |
|
Orthodontia Dental Services |
0% |
40% |
50% |
|
Vision Coinsurance
Amount |
|
COVERED
SERVICES |
Years |
|
1 |
2 |
3 |
|
Exams/refractions |
80% |
80% |
80% |
|
Glasses |
80% |
80% |
80% |
|
Contacts |
80% |
80% |
80% |
|
Hearing Coinsurance Amount |
|
COVERED SERVICES |
Years |
|
1 |
2 |
3 |
|
Exams |
80% |
80% |
80% |
|
Hearing Aids |
80% |
80% |
80% |
|
Get a Quote •
Now!
|
|
Now you can
apply online. This product is
available in the following states:
Louisiana, Oklahoma, Arizona and
Texas |
-
Choose your own dental, vision and
hearing provider
-
Issued to age 75
-
No waiting period for vision
coverage
-
No waiting period for hearing
coverage
-
No waiting period for class I
-
(preventive) dental
coverage
-
Orthodontia services included
|
|
