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Active Lifestyle Dental Plan
|For individuals with effective dates between April 1st, 2016 and March 1st, 2017||In-Network*||Out-of-Network|
|Diagnostic & Preventive Services|
|Diagnostic and preventive services - exams, cleanings, bitewing X-rays and fluoride treatment||100%||80%|
|Brush biopsy - to detect oral cancer||100%||80%|
|Basic Services (6 Month Waiting Period Applies)|
|Emergency Palliative Treatments - to temporarily relieve pain (no waiting period)||100%||80%|
|Radiographs/Diagnostic imaging & casts - X-rays for routine care or for diagnosis of a condition||80%||60%|
|Minor restorative services - to repair teeth damaged by disease or injury (i.e. silver/white fillings)||80%||60%|
|Periodontal Maintenance - maintenance following active periodontal therapy||80%||60%|
|Simple Extractions - including local anesthesia, suturing and post-operative care||50%||50%|
|Other Basic Services - services performed during after-hour visits (12 month waiting period applies)||50%||50%|
|Major Services (12 Month Waiting Period Applies)|
|Oral surgery - extractions/dental surgery, local anesthesia, post-operative care and diagnosis/treatment of TMD||50%||50%|
|Endodontic services - to treat teeth with diseased/damaged nerves (i.e. root canals)||50%||50%|
|Periodontic services - to treat diseases of the gums and supporting structures of the teeth||50%||50%|
|Prosthodontic services - to replace missing natural teeth (i.e. bridges, endosteal implants and dentures)||50%||50%|
|Major restorative services - when damaged teeth can't be restored with filling material (i.e. crowns)||50%||50%|
|Relines and repairs - to fixed/removable bridges and partial/complete dentures (6 month waiting period applies)||80%||60%|
|Maximums and Deductible|
|Annual maximum - Per person on all services - per benefit year||$1,000|
|Annual deductible - Per person/family - per benefit year||$50/$150|
|In- and Out-of-network providers||PPO Fee|
*To ensure that you have access to as many providers as possible Renaissance contracts with various dental networks and treats covered services provided by those network dentists as In-Network for the purposes of this policy. Please note that the allowed amounts your provider may charge will vary based on the network in which he/she participates.
Waiting Periods - All basic services except services performed during after hours will not be covered until after a person is enrolled in the dental plan for 6 consecutive months. All major services except relines and repairs will not be covered until after a person is enrolled in the dental plan for 12 consecutive months.
NOTES: The above summary is a sample of benefits. Policies have exclusions and limitations that may limit coverage. Renaissance Active Lifestyle Plan may not be available in all states. For complete coverage details, please refer to your policy, INVD-100A-2016.
EXCLUSIONS: Cosmetic surgery or dentistry for aesthetic reasons (except reconstructive surgery for children because of congenital disease or anomaly); general anesthesia and/or intravenous sedation; 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 very 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 of America, Indianapolis, IN, and in New York by Renaissance Health Insurance Company of New York, New York, NY. Both companies may be reached at P.O. Box 1596, Indianapolis, IN 46206.
*Renaissance Internal Data, 2016
© 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, New York, NY. Each company has sole financial responsibility for its own products. Products and services referred to are not available in all states and jurisdictions.