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High Plan

 

Benefit Highlights:

Covered services In-network Out-of-network
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%
Brush Biopsy - Used to detect oral cancer 100% 100%
Sealants 100% 100%
Radiographs/diagnostic imaging* - X-rays 100% 100%
Basic Services
Emergency palliative treatment - To temporarily relieve pain 70% 70%
Periodontic Services - Treatment for diseases of the gums and supporting structures of the teeth 70% 70%
Oral surgery services - Extraactions and dental surgery, including local anesthesia, suturing and post-operative care 70% 70%
Minor restorative services - Silver and white fillings 70% 70%
Other basic services - Misc. services 70% 70%
Major Services
Endodontic services - Root canals 50% 50%
Major restorative services - Crowns 50% 50%
Prosthodontic Services - Bridges, dentures and implants 50% 50%
Denture and bridge repiars and relines 20% 40%
Orthodontics
Orthodontic services* - Braces 50% 50%
Orthodontic age limit 19 19
Maximums and Deductibles
Contract year maximum $1,500 per member $1,500 per member
Orthodontic lifetime maximum $1,500 per member $1,500 per member
Deductible (per contract year)
*Deductible waived for these services
$50 per member/$150 per family $50 per member/$150 per family
Allowed Amounts
Allowed Amount PPO Fee 80th percentile
Waiting Periods - Basic Services will not be covered until after a person is enrolled in the dental plan for 6 consecutive months. Major Services will not be covered until after a person is enrolled in the dental plan for 12 consecutive months. Orthodontics will not be covered until after a person is enrolled in the dental plan for 24 consecutive months

 

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.

 


*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, 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.