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MAX Choice Plus Plan
|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%|
|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%|
|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%|
|Orthodontic services - Braces||10%||25%||50%|
|Orthodontic age limit||19||19||19|
|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|
|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|
|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.