Page 6 - Carrier Assistant Benefit

Very Simple to Understand Bene ts for Dental Care
Payment from an indemnity based dental/vision plan is paid by procedure. A typical adult 6 month dental check-up consists of an evaluation, cleaning and bitewings xrays. Based on the chart below, the plans would pay the following bene ts:
Value Standard Royal
Evaluation
$13
$16
$20
Cleaning
$33
$40
$50
Bitewings*
$15
$18
$22
Total
$61
$75
$92
Very Simple to Understand Bene ts for Dental Care
By using one of Ameritas’ preferred dentists or vision providers, you could realize more savings.
Go to www.(INSERT)-BENEFITS.com and select Dental/Vision to find a provider.
*Deductible of $25 would apply
Sample - Schedule of Bene ts Value Standard Royal What the Plan Pays
Type 1 Preventative (no deductible)
Two evaluations per calendar year
Two cleanings per calendar year–Adult Two cleanings per calendar year–Child Fluoride for Children (Under age 19)
$13 each $33 each $22 each $13
$16 each $40 each $27 each $15
$20 each $50 each $34 each $19
Type 2 Basic ($25 deductible)
X-rays - Complete series (including bitewings) Bitewings - Two lms (twice in a calendar year) Amalgam restoration (silver llings) -
One surface, primary or permanent
Extraction - Erupted tooth or exposed root (elevation and/or forceps removal)
Surgical removal of tooth (completely bony) Deep sedation/general anesthesia
$40 $15 $35
$40
$83 $116
$48 $18 $42
$48
$100 $140
$60 $22 $53
$60
$125 $175
Type 3 Major ($25 deductible)
Maxillary partial denture - Resin base
Denture repair - Repair broken base
Endodontics - Root canal, anterior
Periodontal scaling and root planing, four or more teeth Each quadrant is eligible once in a 2-year period Crown - Full cast noble metal
Crown repair
Pontics - Porcelain fused to noble metal
$248 $30 $132 $43
$185 $50 $185
$300 $36 $160 $52
$224 $60 $224
$375 $45 $200 $65
$280 $75 $280
The group policy is governed by the laws of the state of VA. This is an association plan, so coverage is not available in NH due to state laws. Value and Standard Plans are not available in NY.
This information is provided by Ameritas Life Insurance Corp. (Ameritas Life) and Ameritas Life Insurance Corp. of New York (Ameritas of New York). Ameritas Life issues group dental, vision and hearing care products (9000 Rev. 03-16, dates may vary by state) and individual dental and vision products (Indiv. 9000 Rev. 07-16, dates may vary by state) in all states other than New York. Ameritas of New York issues group dental, vision and hearing care products (9000 NY Rev. 03-15) and individual dental and vision products (Indiv. 9000 NY Rev. 07-16) in New York. Ameritas, the bison design, “ful lling life” and product names designated with SM or ® are service marks or registered service marks of Ameritas Life, af liate Ameritas Holding Company or Ameritas Mutual Holding Company. All other brands are property of their respective owners. © 2017 Ameritas Mutual Holding Company.
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