Page 13 - Hospice Benefits Enrollments Guide

Dental Benefits

Dental Benefits by Ameritas

100% UCR
• Routine Exam (2 per benefit period)
• Cleanings (4 per benefit period)
Diagnostic & Preventive • Bitewings X-rays (1 per benefit period)
Services • Full Mouth/Panoramic X-rays (1 in 3 years)
• Fluoride for Children 18 and under (2 per benefit period)
• Sealants (age 15 and under)
• Space Maintainers
80% UCR
• Restorative Amalgams
• Restorative Composites
Basic Services
• Simple Extractions
• Complex Extractions
• Anesthesia
50% UCR
• Onlays
• Crowns (1 in 5 years per tooth)
• Crown Repair
Major Services
• Endodontics
• Periodontics
• Denture Repair
• Prosthodontics (1 in 5 years)
50% UCR
• For dependent children to age 19
Orthodontics • Diagnostic, active, retention treatment
• $1,500 lifetime orthodontic maximum (per person)

Individual $50
Plan Year Deductible
Family $150
Plan Year Maximum $1,500

SM
Plan includes Preventive Plus which means, no claims paid for diagnostic and preventive services will count
against your $1500 plan year maximum.
This plan includes Dental Rewards® which allows you to qualify to carry over part of your unused annual dental
maximum benefit. You must submit at least one claim during the benefit year with a total claims paid of $750 or
less in order to qualify for an annual carry over amount of $250. You can earn an additional PPO bonus of $150 if
you see a network provider. (Maximum carryover for dental reward is $1,000 combined.)

12 |