Page 4 - Affinity Neurocare Benefit Guide - FINAL

Voluntary Dental Options:

Ameritas

Per Pay Period Bi-Weekly (26) Dependent Information

Employee Only $16.74 We offer our employees their dependents dental coverage.
Employee + Spouse $35.58 Children can join or remain on a parent’s dental plan until
age 26. When a child turns 26, they will lose dental coverage
Employee + Child(ren) $38.69
on the last day of their birth month.
Employee + Family $55.53

BRIEF OVERVIEW Amount You Pay Amount You Pay
Non-Network Dentists
Type of Service In—Network Dentists Reimbursed at 90% of U&C

Annual Deductible (CYD) $0-$25 Individual / $75 Family Max $0-$25 Individual / $75 Family Max

Preventive Services Covered at 100%; CYD Waived Covered at 100%; CYD Waived

Basic Services Covered at 80% after CYD Covered at 80% after CYD

Major Services Covered at 50% after CYD Covered at 50% after CYD
Annual Maximum $1,000 $1,000

Annual Maximum Preventive Services Does Not Apply Preventive Services Does Not Apply

CY Max will increase: CY Max will increase:
Annual Maximum 2nd year $100 (to $1,100) 2nd year $100 (to $1,100)
(5 Year Increase) 3rd year $200 (up to $1,300) 3rd year $200 (up to $1,300)
4th year $300 (up to 1,600) 4th year $300 (up to 1,600)
5th year $400 (up to $2,000. 5th year $400 (up to $2,000.

Type of Service Benefit Description

See Summary of Benefits and Policy for the age and frequency limitations of benefits.

Covered at 100% Routine Exams,
Preventive Services Cleaning (2 /year), topical fluoride, X- 100% of Reasonable and Customary
rays, space maintainers, sealants.

Covered at 80% Composite fillings,
Basic Services extractions, endodontics, 80% of Reasonable and Customary
periodontics, oral surgery

Covered at 50% Crown, Bridges,
Major Services 50% of Reasonable and Customary
Dentures, Implant Alternate
Annual Maximum Applies January 1 to December 31 Applies January 1 to December 31

Network and non Network In Network Non Network

NOTE: This is only a brief overview. Please see Benefit Summary and policy for more details.
Website: ameritas.com or Customer Service : 800-659-2223
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