Dental Plan Details

Combined Calendar Year Deductible
$50.00 per individual for Type I (Basic) and Type II (Major) Procedures.

3 Times Family Limit: after the date that 3 members of a family have each satisfied their individual deductible, the entire deductible or any remaining portion of the deductible for any family member will be waived for the rest of that calendar year.

Type I (A) - Preventive and Diagnostic
Type (A) benefits are payable at 100% UCR*. No deductible applies.
• Exams (Two per benefit period)
• Cleanings (Two per benefit period)
• Fluoride for Children (Under age 19)
• Space Maintainers
• Radiographs (X-rays)

Type I (B) - Basic Procedures
Type (B) benefits are payable at 80% UCR*. $50.00 deductible applies.
• Sealants (Under age 17)
• Fillings
• Oral Surgery - Simple Extractions
• Denture Repair
• Periodontics
• Endodontics

Type II - Major Procedures*
Type II benefits are payable at 50% UCR*. $50.00 deductible applies.
• Oral Surgery
• Inlay & Onlays
• Crowns
• Crown Repair
• Bridges/ Pontics
• Partials & Dentures

The above is a sample list of dental procedures (within each category) payable under this plan. Please refer to your certificate booklet for complete details.

Orthodontia (for Adults & Children)
Paid at 50% UCR* with a $1,000 Lifetime Max. No deductible applies. There is no waiting period for Orthodontics.
• Orthodontia Procedures - $1,000 Lifetime per person

Annual Maximum Carryover
1. Visit a dentist between January 1 and December 31 of each year.
2. Submit a claim for a covered procedure prior to March 1 of the following year.
3. Total dental benefits paid for the calendar year must be less than $500.

If you meet all 3 requirements then you will be eligible for the Annual Maximum Carryover benefit. This benefit will provide you with an additional $250 towards your annual dental maximum for the following year. In future years, if you continue to meet these requirements you will continue to see an increase in your annual maximum by $250 until you have reached an annual maximum carryover limit of $1000. This benefit allows you to accumulate up to a $2,000 annual dental maximum.

Late Entrant Provision
There is a 12 month waiting period on all services except cleanings, exams and fluoride treatments for employees who do not enroll when first eligible for coverage. Waived for employees who enroll during the initial enrollment period.

Annual Maximum Benefit
• Type I (A)(B) and Type II Procedures - $1,000 per calendar year per person

Dental Exclusions (Deferment Period)
During the first 36 months following you or your dependent's Dental Coverage Effective Date, the initial placement of dentures, partial dentures, or bridges, if it includes the replacement of teeth all of which are missing prior to the effective date. For currently covered insureds, Ameritas will use the employees Date of Hire to determine the 36 month period.

This exclusion will not apply if the prosthesis replaces a sound natural tooth which is extracted while the patient is insured under this Dental Coverage and which is replaced within 12 months of the extraction. During the first 36 months of coverage, the replacement of bridges, partial dentures, dentures, inlays or crowns are excluded.

EXCEPTIONS to this exclusion will be made if the replacement is made necessary by:
a) accidental bodily injury to sound natural teeth (chewing injuries are not considered accidental bodily injuries), or
b) the extraction of a sound natural tooth provided the replacement is completed within 12 months of the date of this inquiry or extraction.

Limitations/Exclusions (not a complete list):
• For any treatment which is for cosmetic purposes. Facings on crowns or pontics behind the 2nd bicuspid are considered cosmetic.
• Charges incurred prior to the date the individual became insured under this plan, or following the date of termination of coverage.
• Services which are not recommended by a dentist or which are not required for necessary care and treatment.
• Expenses incurred to replace lost or stolen appliances.
• Expenses incurred by an insured because of a sickness for which he /she is eligible for benefits under Worker's Compensation Act or similar laws.

Orthodontia Limitations (This is not a complete list):
No benefit is payable for expenses incurred:
• In connection with a Treatment Program which was begun before the individual became insured for orthodontic benefits.
• During any quarter of a Treatment Program if the individual was not continuously insured for orthodontic benefits for the entire quarter.
• After the individual's insurance for orthodontic benefits terminates.

Pre-Determination of Benefits
A treatment plan MAY be filed if a proposed course of treatment will exceed $200.00. With this information, Ameritas can determine the benefits payable under this policy prior to the work actually being done. It will give the insured the amount payable, along with an idea of the out of pocket expense.

Coordination of Benefits
If you or any of your dependents incur charges which are covered by any other group plan, the benefits of this plan will be coordinated with the benefits of the other plan so that the total benefits received are not greater than the charges incurred.

Certificate of Insurance
The Certificate of Insurance issued to you describes in detail the benefits and limitations of this plan. This brochure is for general information only.

Eligible Employees
You are eligible for insurance if you are a full-time active employee working at least 30 hours per week.

Eligible Dependents
Provides Coverage On:
• Your Spouse
• Children, up to age 24 regardless of student status.

Section 125
This policy is provided as part of the Policyholder's Section 125 Plan. Each member should complete an enrollment form and turn it in to the Payroll Department.

A member may change their election only during an annual election period, except for a change in family status. Examples of such events would be marriage, divorce, birth of a child, death of a spouse or child or termination of employment. Please see your plan administrator for details.

This insurance is underwritten by Ameritas Life Insurance Corp.

 
 

Monthly Dental Rates

10-Pay deductions

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