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 $1,250 per person.

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	$1,000 $1,250
Deductible
Per Individual Benefit Year (max 3 per family) ......................................	$50
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 ...............................	$1,000

Type I Preventive Dental Services, Including

- Routine Oral Exams
- Routine Dental Cleanings
- Fluoride Treatment (children under 14)
- Sealants (children under 16)
- Space Maintainers (children under 16)
- Harmful Habit Appliance (children under 16)
- Bitewing X-Rays

Type II Basic Dental Services, Including

- X-Rays
   - Complete Series
   - Panoramic
   - Other X-Rays (See Certificate of Insurance)
- New Fillings: Replacement Fillings
- Simple Extractions, Removal of Exposed Roots, Incision and Drainage
- Certain Lab Tests, Pain Treatment, Therapeutic Drug Injections

Type III Major Dental Services, Including:

- Endodontics
- Endodontic Retreatment
- Complex Oral Surgery
- Minor Gum Disease Treatment
   - Provisional Splinting, Occlusal Adjustments
   - Scaling and Root Planing
   - Periodontal Maintenance
- Major Gum Disease Treatment
   - Gingivectomy, Osseous Surgery, Other Major Periodontic Procedures
- Initial Placement, Replacement and Maintenance of Inlays, Onlays, Crowns, Fixed Partial Dentures (Bridges), and Partial and Complete Dentures

Type IV Orthodontic Dental Services

Only for dependent children under age 19
- Limited Orthodontic Treatment
- Interceptive Orthodontic Treatment
- Comprehensive Orthodontic Treatment
- Minor Treatment to control harmful habits
- 12 Month Waiting Period

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.