Insured Plan

Insured Dental Plan (PDF Brochure)

The Insured Plan provides you with a choice of any dentist or specialist you choose. Coverage includes dental and a discount vision benefits for one low cost, through payroll deduction.

New expanded PPO network! Use the optional PPO network and save an additional 30% when you go to a Dentist or Specialist. Max per calendar year benefit also increased to $2,000 per person In-Network & $1,500 Out-of-Network.

Click here to search for a PPO Dentist or Specialist in your area.

Payroll Deduction

	Bi- weekly (24)	Monthly
Employee	$21.78	$43.55
Employee and 1 Dependent	$41.81	$83.61
Employee and 2 or More Dependents	$49.42	$98.83
Employee and 3 or More Dependents	$65.18	$130.35

FREEDOM ADVANCE ^SM

Benefit Maximum
Per Individual Benefit Year ...................................... in optional PPO network	$1,500 $2,000
Deductible
Per Individual Benefit Year ($100 per family) ......................................	$50 Indiv.
Applies to Type II and III Services Only
Coinsurance Percentage
Per Individual Benefit Year
	Type I	Type II	Type III
During the 1^st year ..................................................	100%	80%	25%
During the 2^nd year .................................................	100%	80%	50%
During the 3^rd year and thereafter ..........................	100%	80%	50%
Type IV Dental Services .........................................	50%
Lifetime Orthodontia Maximum ...............................	$1,500

Type I Preventive Dental Services, Including

- Routine Oral Exams (once every 6 months in a row)
- Routine Dental Cleanings (once every 6 months)
- Fluoride Treatment (once every 6 months in a row) (children under 14)
- Sealants - Once per tooth per 36 month period, only for permanent molar teeth (children under 16)
- Space Maintainers (children under 16)
- Harmful Habit Appliance (children under 16)
- Bitewing X-Rays - Once every 12 months

Type II Basic Dental Services, Including

- Endodontics (Includes root canal therapy)
- Endodontic retreatment (covered after 24 months have passed from initial treatment)
- X-Rays
   - Complete Series - once every 60 months
   - Panoramic - once every 60 months (may also be payable in connection with the removal of impacted teeth)
   - Other X-Rays (See Certificate of Insurance)
- New Fillings, Replacement Fillings - once every 24 months per Filling
- Simple Extractions, Removal of Exposed Roots, Incision and Drainage
- Certain Lab Tests, Pain Treatment, Therapeutic Drug Injections

Type III Major Dental Services, Including:

- Complex Oral Surgery: General Anesthesia and IV Sedation when medically required for such surgery
- Minor Gum Disease Treatment: (Minor Periodontics)
   - Provisional Splinting, Occlusal Adjustments (Once every 12 months)
   - Scaling and Root Planing (Once every 24 months per area)
   - Periodontal Maintenance (Once every 6 months)
- Major Gum Disease Treatment (Major Periodontics)
   - Gingivectomy, Osseous Surgery, Other Major Periodontic Procedures (Once every 36 months per area)
- Crowns, Initial Placement, Replacement and Maintenance of Inlays, Onlays, Fixed Partial Dentures (Bridges), and Partial and Complete Dentures

Type IV Orthodontic Dental Services

Only for dependent children under age 19 - No Waiting Period
- Limited Orthodontic Treatment
- Interceptive Orthodontic Treatment
- Comprehensive Orthodontic Treatment
- Minor Treatment to control harmful habits

This page includes a brief summary of the insured plan benefits. A complete description of insured benefits, including limitations and exclusions, will be provided in the Certificate of Insurance.

The percentage paid is based on the allowable charges which are current charges for the area where the services are performed.