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Creative Solutions for Creative People. ™ |
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Individual Dental Insurance
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Preventive & Diagnostic Services |
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Coverage
One initial examination per calendar year
Two prophylaxis (cleaning) per calendar
year
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Preferred Provider
Pays 100% of PPO
$50 annual deductible*
No waiting period
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Non-Preferred Provider
Pays 80% of U&C
$50 annual deductible
No waiting period
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Basic Restorative Services |
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Coverage
Bitewing x-rays, two per calendar year
One fluoride treatment per calendar year
for dependents under age 16
Simple restorative services (fillings)
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Preferred Provider
Pays 70% of PPO
$50 annual deductible*
6-mo. waiting period
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Non-Preferred Provider
Pays 50% of U&C
$50 annual deductible
6-mo. waiting period
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Major Services |
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Coverage
Oral surgery
Bridge
Periodontics
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Preferred Provider
Pays 50% of PPO
$50 annual deductible*
18-mo. waiting period
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Non-Preferred Provider
Pays 50% of U&C
$50 annual deductible
18-mo. waiting period
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* Combined Preventive, Basic and Major calendar year deductible maximum is
$150 per family. combined calendar year maximum benefit amount for Preventive,
Basic and Major is $1,000 per Person.
Note: This is a general outline of covered benefits and does not include all
the benefits, limitations, and exclusions of the policy. See your certificate
for details.
Claims will not be applied to your deductible until the applicable waiting
period has been met.
| Rate Schedule (monthly) |
Minnesota Region |
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• Single
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$30.17 |
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• Single + 1
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$56.57 |
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• Single + Family
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$85.99 |
Rates are effective July 15, 2007. Premiums are subject to change with 30 days notice.
Click
here to Find a Preferred Provider Dentist
(Choose
find a dentist, use the Premier Classic network)
Apply
Online - Click Here
Print an Application - Click Here
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