PLANS FOR FAMILIES AND ADULTS WITH BASIC COVERAGE Features & Benefit Details

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Grant Dennis
7 years ago
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1 Page 1 of 7 PLAN NETWORK Premier Participating Dentists PPO Blue Cross PPO Preferred Dentist Program Plus DentalGuard Preferred Premium range child under age 19** $36-$55 $31-$41 $32 $30-$34 $23-$29 Sample premium range typical family of 4** $105-$163 $102-$133 $80 $101-$116 $106-$134 Is this a smaller network? No No Yes No No Is there out-of-network coverage? Annual deductible one enrollee $50 Annual deductible family $150 Maximum out-of-pocket child under 19 yrs. $1,000 Maximum annual out-of-pocket 2 or more children $2,000 Maximum annual per person benefit (adults 19 and over only) $750 Yes **Premiums shown are samples for comparison purposes. Actual premiums will vary depending on your group composition and effective date. Please call MA-ENROLL to obtain a quote.

2 Page 2 of 7 Type I services: Preventive & Diagnostic Co-insurance percent (what you pay) PPO All ages in-network 0% out-of-network 20% Comprehensive Evaluation Periodic Oral Exams Oral Evaluation under 3 years of age Teeth cleaning Full Mouth X-Rays Panoramic X-rays 1 per patient per location per lifetime patient per 12 patient per 36 patient per 12 Single tooth X-Rays Bitewing X-Rays patient per 12 4 Procedures per patient per 12 patient per 12 Periodontal Cleaning 3 Fluoride Treatments Space Maintainers Sealants tooth per 36

3 Page 3 of 7 Comprehensive Evaluation Periodic Oral Exams Teeth cleaning Full Mouth X-Rays Panoramic X-Rays 1 per patient per 60 patient per 12 patient per 60 patient per 12 2 per patient per 12 patient per 36 patient per 36 Bitewing X-Rays Single tooth X-Rays Periodontal Cleaning Fluoride Treatments Space Maintainers Sealants 3 For enrollees 19 yrs. and over PPO

4 Page 4 of 7 Type II services: Basic Restorative Services Co-insurance percent (what you pay) All ages: in-network 25% out-of-network 45% Silver Fillings White Fillings tooth per surface per 12 Temporary Fillings Prefabricated Stainless Steel Crowns Periodontal Scaling and Root Planing Root canals on permanent teeth Apicoectomy 1 Procedure per quadrant per 36 tooth per lifetime 1 Procedure per quadrant per 24 PPO Vital Pulpotomy Simple extractions Surgical extractions General Anesthesia Intravenous Conscious Sedation Treatment for Minor Pain Relief

5 Page 5 of 7 For enrollees 19 yrs. and over Silver Fillings White Fillings tooth per surface per 24 Temporary Fillings Periodontal Scaling and Root Planing Root canals on permanent teeth Apicoectomy Simple extractions Surgical extractions General Anesthesia Intravenous Conscious Sedation Treatment for Minor Pain Relief quadrant per 24 tooth per lifetime PPO quadrant per 36

6 Page 6 of 7 PPO Under 19: 19 and over: Type III services: Major Restorative in-network 50% in-network 100% Co-insurance percent (what you pay) out-of-network 70% out-of-network 100% Waiting period None Crowns Partial & complete dentures Implants tooth per 60 arch per 84 arch per 60 For enrollees 19 yrs. and over Waiting period N/A Crowns Partial & complete dentures Implants

7 Page 7 of 7 PPO Under 19: 19 and over: Type IV services: Orthodontia in-network 50% Not coverd Co-insurance percent (what you pay) out-of-network 70% Medically necessary orthodontia Prior authorization is required; patient per lifetime

Plans for Families and Adults with Comprehensive Coverage Features & Benefit Details

Plans for Families and Adults with Comprehensive Coverage Features & Benefit Details Page 1 of 7 s for Families and Adults with Comprehensive Coverage Network Premier Altus Dental Participating Dentists Blue Cross PPO Dental Preferred Dentist Program Plus EPO Family EPO DentalGuard Preferred