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Basics |
Intermediate |
Plus |
|
|---|---|---|---|
| Preventative Services | |||
| Two visits per person each policy year separated by at least 150 days. | |||
| Exams, X-rays, cleanings: | $5,000 | $7,500 | $7,500 |
| Basic Services | |||
| Payments are 50% of the listed benefit in the first policy year. After the first year, you receive 100% of the benefit. | |||
| Deep Sedation/General Anesthesia: | $140 | $275 | $275 |
| Amalgam Filling-3 Surfaces: | $70 | $140 | $140 |
| Extraction-Erupted Tooth or Exposed Root: | $50 | $100 | $100 |
| Reline Completure Denture (Laboratory): | $150 | $300 | $300 |
| Major Services | |||
| For the Plus plan, there is a 180-day waiting period on major services in most states. After the waiting period, payments are 50% of the listed benefit for the remainder of the first policy year. After the first year, you receive 100% of the benefit. Major Services are not covered under the Basic plan. | |||
| Inlay-Metallic-2 Surfaces: | N/A | N/A | $330 |
| Crown-Resin: | N/A | N/A | $250 |
| Retreatment of Pervious Root Canal; Therapy-Bicuspid: | N/A | N/A | $250 |
| Complete Denture: | N/A | N/A | $375 |
| Maxillary Sinusotomy: | N/A | N/A | $825 |
| Annual Benefit | $500 Basic Services |
$1,000 Basic Services |
$1,500 Basic + Major Services combined |