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Dental Benefit Details

This document summarizes the details of a dental insurance plan. It lists the monthly premium as $88.69 with a 15% discount eligibility. Coverage includes unlimited annual maximum benefits and no deductibles. Preventative services are covered at no charge both in-network and out-of-network. Basic services have copays of $100 in year 1 and $50 in year 2. Major services have tiered copays that decrease in the second year. The plan also covers routine dental services, dental checkups for children, and major/basic dental care for both children and adults.

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Fernanda Vargas
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21 views3 pages

Dental Benefit Details

This document summarizes the details of a dental insurance plan. It lists the monthly premium as $88.69 with a 15% discount eligibility. Coverage includes unlimited annual maximum benefits and no deductibles. Preventative services are covered at no charge both in-network and out-of-network. Basic services have copays of $100 in year 1 and $50 in year 2. Major services have tiered copays that decrease in the second year. The plan also covers routine dental services, dental checkups for children, and major/basic dental care for both children and adults.

Uploaded by

Fernanda Vargas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Plan Details

PPO Estimated Monthly Premium: $88.69/mo


Eligible for 15% discount

Select Dental Copay Plan 2 Plan Cost


$88.69

 Provider Lookup Network: Aetna Dental Administrators

Benefits

In Network Out of Network

Annual Deductible Not Applicable Not Applicable

Annual Maximum Unlimited Unlimited

Diagnostic Services Plan Brochure Plan Brochure

Preventive Services You Pay: No Charge Copay/Visit You Pay: No Charge Copay/Visit

Basic Services You Pay: Year 1: $100; Year 2: $50 Copay/Procedure You Pay: Year 1: $100; Year 2: $50 Copay/Procedure

Access To Providers Any network provider Plan Brochure

Tier 1: $125/Procedure(year 1), $75/Procedure(year 2); Tier 1: $125/Procedure(year 1), $75/Procedure(year 2);
Major Services
Tier 2: $500/Procedure(year 1), $350/Procedure(year 2) Tier 2: $500/Procedure(year 1), $350/Procedure(year 2)

Endodontics Plan Brochure Plan Brochure

Periodontics Plan Brochure Plan Brochure

Prosthodontics Plan Brochure Plan Brochure


Orthodontics Not Applicable Not Applicable

Dental

In Network Out of Network

Routine Dental Services (Adult) You Pay: No Charge Copay/Visit You Pay: No Charge Copay/Visit

Dental Check-Up for Children You Pay: No Charge Copay/Visit You Pay: No Charge Copay/Visit

Tier 1: $125/Procedure(year 1), $75/Procedure(year 2); Tier 1: $125/Procedure(year 1), $75/Procedure(year 2);
Major Dental Care – Child
Tier 2: $500/Procedure(year 1), $350/Procedure(year 2) Tier 2: $500/Procedure(year 1), $350/Procedure(year 2)

Basic Dental Care – Child You Pay: Year 1: $100; Year 2: $50 Copay/Procedure You Pay: Year 1: $100; Year 2: $50 Copay/Procedure

Basic Dental Care – Adult You Pay: Year 1: $100; Year 2: $50 Copay/Procedure You Pay: Year 1: $100; Year 2: $50 Copay/Procedure

Tier 1: $125/Procedure(year 1), $75/Procedure(year 2); Tier 1: $125/Procedure(year 1), $75/Procedure(year 2);
Major Dental Care – Adult
Tier 2: $500/Procedure(year 1), $350/Procedure(year 2) Tier 2: $500/Procedure(year 1), $350/Procedure(year 2)

Additional Plan Information


Provider Directory Plan Brochure

NOTICE! Final rates and benefits are based on actual plan selection (including plan riders you may request) and the assignment of any rate adjustment factors due to the
Dental plan's underwriting guidelines.

IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not
subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change
without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are
your share of the costs for covered benefits.

Rate and Benefit Disclaimer Notification! Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's
rates and benefits from the insurance company.

Additionally, information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions
of the referenced benefit plans. Only the insurance company Plan Documents and Policy contain the exact terms and conditions of coverage. Your grant of access to the rate
and benefit summaries contained herein may not be relied upon as a guarantee of your eligibility or coverage under these benefit plans.
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