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Ameritas Dental Plan Details
Combined Calendar
Year Deductible
$50.00 per individual for Type 2 (Basic) and Type
3 (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 1 Preventive and
Diagnostic -
Type 1 benefits are payable at 100%
U&C*. No deductible applies.
• Evaluations (Two per benefit period)
• Space Maintainers
• Cleanings (Two per benefit period)
• Radiographs (X-rays)
• Fluoride for Children (Under age 19)
• Bitewings (Two per benefit period)
• VSP Eye Exam
Type 2 Basic Procedures -
Type 2 benefits are payable at 80%
U&C*.
$50.00 deductible applies.
• Sealants (Under 17)
• Oral Surgery - Complex Extractions
• Limited Exams - problem focused
• Anesthesia
• Restorative Amalgam & Resin (excluding inlays and crowns)
• Denture Repair
• Endodontics ( Root Canal)
• Periodontics (Gum Disease)
• Oral Surgery - Simple Extractions
Type 3 Major Procedures* -
Type 3 Benefits are payable at 50%
U&C*. $50.00
deductible applies.
• Restorative - Inlays and Crowns
• Prosthodontics - Removable Dentures, Partials
• Prosthodontics - Fixed Pontics or Abutments
• Crown Repair
Orthodontia - Paid at 50%
U&C* with a $1,000 lifetime maximum.
No deductible applies. Applies to both adults and children.
Annual Maximum Benefit
• Type 1, Type 2 Procedures and Type 3 Procedures - $1,000 per calendar year per
person.
• Orthodontia Procedures - $1,000 Lifetime per person.
Section 125
This policy is provided as part of the Policyholder's Section 125 Plan. Each
member has the option under the Section 125 Plan of participating or not
participating in this policy. 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.
Dental Exclusions (deferment
Period)
During the first 36 months following your 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 is
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 the injury or extraction.
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 19 and unmarried (Up to age 24 if wholly dependent upon you
for maintenance and support and if enrolled as a full-time student in an
accredited school or college.)
Predetermination 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.
IMPORTANT NOTE
Late Entrant Notice: There is a 12 month waiting period on all procedures
except cleanings, exams, and fluoride treatments - unless the employee (and/or
his family members) enrolled in the plan when they were first eligible to
participate.
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.
Limitations/Exclusions
(This is 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.
Semi-Monthly Dental Rates
|
Employee |
$14.48 |
| Employee & Spouse | $29.03 |
| Employee & Child(ren) | $30.66 |
| Family | $45.21 |
*Usual & Customary
