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MAX Choice Plus Plan

 

Benefit Highlights:

Covered services 1st Year 2nd Year 3rd Year
Diagnostic & Preventive Services
Diagnostic and Preventive Services - Includes exams and cleanings twice per year, bitewing X-rays and fluoride treatments to age 14 100% 100% 100%
Brush Biopsy - Used to detect oral cancer 100% 100% 100%
Basic Services
Fluoride treatment - Topical application of fluoride 40% 60% 80%
Bitewing Radiographs - Bitewing X-rays 40% 60% 80%
Sealants - To prevent decay of permanent molars 40% 60% 80%
Emergency palliative treatment - To temporarily relieve pain 40% 60% 80%
Space Maintainers - To maintain space 40% 60% 80%
Major Services
All other radiographs - Other X-rays 20% 40% 50%
Minor restorative services - Fillings 20% 40% 50%
Periodontic Services - To treat gum disease 20% 40% 50%
Endodontic Services - Root canals 20% 40% 50%
Relines and repairs - To bridges, implants and dentures 20% 40% 50%
Oral surgery services - Extractions and dental surgery 20% 40% 50%
Major restorative services - Crowns 20% 40% 50%
Prosthodontic services - Bridges, implants, and dentures 20% 40% 50%
Orthodontics
Orthodontic services - Braces 10% 25% 50%
Orthodontic age limit 19 19 19
Maximums
Policy year maximum payment - Applies to Diagnostic and Preventive, Basic and Major Services $1,000 $2,000 $3,000
Orthodontic lifetime maximum $1,200 $1,200 $1,200
Annual deductibles
Individual policy year deductible - Per enrollee applies to all services except Diagnostic and preventive services and Orthodontics $50 $50 $50
Family policy year deductible - Maximum deductible charged per family applies to all services except Diagnostic and Preventive and Orthodontics $150 $150 $150
Note: Annual deductible is waived for in-network Preventive and Diagnostic services      
Allowed Amounts
In-network providers PPO Fee PPO Fee PPO Fee
Out-of-network providers 80th percentile 80th percentile 80th percentile
Waiting periods - None  

 

NOTES: The above summary is a sample of benefits. Policies have exclusions and limitations that may limit coverage. For complete coverage details, please refer to your policy.

Exclusions: Charges or treatment for correction of congenital or developmental malformations or dentistry for aesthetic reasons; general anesthesia and/or intravenous sedation; cosmetic surgery (except reconstructive surgery for children because of congenital disease or anomaly); treatment by anyone other than a licensed dentist or dental hygienist; veneers, sealants, prosthodontics (implants), prefabricated crowns as final restoration on permanent teeth and paste-type root canal fillings on permanent teeth; appliances, procedures and restorations for increasing vertical dimension, occlusion, tooth structure loss due to attrition, abrasion or erosion, or for periodontal splinting; orthodontic services; space maintainers; lost, missing or stolen appliances; services not in the Policy and/or Summary of Dental Plan Benefits.

Limitations: Coverage for services may be limited based on the age of the person receiving services; coverage for certain services may be limited to a maximum number of occurrences during a specified time period (such as two times per year or one time every three years); coverage for temporomandibular disorders (TMD) is limited.

The premium rate will vary between plans. The policy has a term of one year and will automatically renew (upon payment of required premium) unless terminated in accordance with the policy provisions. Coverage may be terminated for reasons stated in the policy. Coverage ceases upon termination of the policy. Products and services referred to in this brochure may not be available in all states or jurisdictions. Underwritten by Renaissance Life & Health Insurance Company, Indianapolis, IN, and in New York by Renaissance Health Insurance Company of New York, New York, NY. Both companies may be reached at PO Box 1596, Indianapolis, IN 46206.

 



 

© 2016 Renaissance Holding Company | All Rights Reserved | PO Box 1596, Indianapolis, IN 46206-1596
Underwritten by Renaissance Life & Health Insurance Company of America, Indianapolis, IN and in New York by Renaissance Life & Health Insurance Company of New York, Binghamton, NY. Each company has sole financial responsibility for its own products. Products and services referred to are not available in all states and jurisdictions.