Page 61 - SMS WV Overview.pdf

Dental Rewards ® Limitations and exclusions

By visiting a dentist each year and submitting total Covered expenses will not include and no benefits will be payable for
claims less than $500, members qualify to carry expenses incurred:
• for any procedure except exams, cleaning and fluoride applications
over $250 to add to their next year’s annual maximum for the first 12 months when an employee or dependent becomes
benefit. And members receive an extra $100 carry-over classified as a late entrant. An employee or dependent who does
reward by visiting an Ameritas Dental Network provider. not enroll within 31 days from the date the person qualifies for the
insurance, or who elects to become covered again after canceling a
Maximum carry-over accumulation is $1,000. premium contribution agreement, will be classified as a late entrant.
Network provider reward not available in MT or RI. • for any treatment which is for cosmetic purposes, except as
specifically listed in the Table of Dental Procedures.
• to replace any prosthetic appliance, crown, inlay or onlay restoration,
LASIK Advantage ® or fixed partial denture within eight years of the date of the last
placement of these items. However, if a replacement is required
LASIK Advantage provides coverage for LASIK and because of an accidental bodily injury sustained while the plan
related procedures. Members earn a lifetime benefit per eye member is covered under the dental expense benefit, it will be a
and the benefit amount increases over a three-year period. Covered Expense.
Members earn benefits for each eye and can’t combine • for initial placement of any dental prosthesis or prosthetic crown
unless such placement is needed because of the extraction of one
benefits for both eyes to use for a single eye. If a member or more teeth while the plan member is covered under the dental
enrolls after the initial enrollment period, they must wait 12 expense benefit. The extraction of a third molar (wisdom tooth) will
months from enrollment to be eligible for coverage; after not qualify under the above. Any such dental prosthesis or prosthetic
crown must include the replacement of the extracted tooth or teeth.
12 months the member will begin coverage at the year-one • for any procedure begun before the plan member was covered under
benefit. The LASIK Advantage benefit is available to members the dental expense benefit.
age 18 and older. There is no network tied to this coverage. • for any procedure begun after the member’s insurance under the
dental expense benefit terminates; or for any prosthetic dental
LASIK coverage is not available in FL. appliances installed or delivered more than 90 days after the
member’s insurance under the dental expense benefit terminates.
Lifetime Benefit Year One Year Two Year Three • to replace lost or stolen appliances.
Earned Per Eye $175 $175 $350 • for appliances, restorations, or procedures to:
– alter vertical dimension;
– restore or maintain occlusion;
SoundCare ® – splint or replace tooth structure lost because
of abrasion or attrition
Benefits are available for hearing exams, hearing • for any procedure which is not shown on the Table of
aids, and hearing aid maintenance. Dental Procedures.
• for orthodontic treatment (unless otherwise specified in
• Exams: Members receive a $75 allowance per benefit this contract.)
period for a comprehensive hearing exam. • for which the plan member is entitled to benefits under any
workmen’s compensation or similar law, or charges for services
• Hearing aids: The plan pays 50% of the hearing aid or supplies received as a result of any dental condition caused or
cost up to the maximum benefit. contributed to by an injury or sickness arising out of or in the course
of any employment for wage
• Maintenance: There is a $40 allowance per benefit or profit.
period for maintenance, batteries, service contracts, • for charges for which the plan member is not liable or which would
fittings, ear molds, and repairs. not have been made had no insurance been in force.
• for services which are not required for necessary care and treatment
or are not within the generally accepted parameters of care.
Hearing aid maximum benefit • because of war or any act of war, declared or not.
The hearing aid benefit is progressive, rewarding loyal • for a Program which was begun on or after the member’s 19th
employees with an amount that increases over time. birthday.
• in any quarter of a Program if the member was not covered under
the orthodontic expense benefits for the entire quarter.
Year One Year Two Year Three + • after the member’s insurance under the orthodontic expense benefits
$100 $300 $400 terminates.
Each amount above is the total hearing benefit available
for each ear. Once plan members use their hearing aid
coverage—no matter how many years they’ve been on the
plan—they become re-eligible for the Year 3+ benefit after
five years, as long as there is no break in coverage.
Hearing coverage not available in FL (hearing with LASIK not available for
groups of less than 51 lives), MA, MT, NH, NM.