Plan III
With excellent coverage for minor services like fillings and denture repair, you’ll have a few more reasons to keep smiling.
Plan III features:
- No waiting periods on preventive care—Immediate coverage for cleanings and exams.
- 100% coverage for diagnostic and preventive services—When you visit a dentist in our nationwide PPO network.
- Affordable—No deductible for preventive services, and a $50 deductible for other services makes Plan III cost-effective.
Benefit Highlights
| Dental Services | In-Network | Out-of-Network |
| Plan Pays | Plan Pays | |
Diagnostic and Preventive Services | ||
| Diagnostic and Preventive Services* Exams, cleanings, bitewing X-Rays and fluoride treatment | 100% | 80% |
| Brush biopsy to detect oral cancer | 100% | 80% |
Basic Services (6 Month Waiting Period Applies) | ||
| Emergency Palliative Treatments to temporarily relieve pain (no waiting period) | 100% | 80% |
| Radiographs/Diagnostic Imaging & Casts X-rays for routine care or for diagnosis of a condition | 80% | 60% |
| Minor Restorative Services to repair teeth damaged by disease or injury (i.e. silver/white fillings) | 80% | 60% |
| Periodontal Maintenance maintenance following active periodontal therapy | 80% | 60% |
| Simple Extractions including local anesthesia, suturing and post-operative care | 50% | 50% |
| Other Basic Services services performed during after-hour visits (12 month waiting period applies) | 50% | 50% |
Major Services (12 Month Waiting Period Applies) | ||
| Relines and Repairs Relines and repairs to fixed bridges, removable bridges, partial dentures, and complete dentures (6 month waiting period) | 80% | 60% |
| Oral Surgery extractions/dental surgery, local anesthesia, post-operative care and diagnosis/treatment of TMD | 50% | 50% |
| Endodontic Services to treat teeth with diseased/damaged nerves (i.e. root canals) | 50% | 50% |
| Periodontic Services to treat diseases of the gums and supporting structures of the teeth | 50% | 50% |
| Prosthodontic Services to replace missing natural teeth (i.e. bridges, endosteal implants and dentures) | 50% | 50% |
| Major Restorative Services when damaged teeth can’t be restored with filling material (i.e. crowns) | 50% | 50% |
| Crown and Cast Restorations Metal and porcelain crowns | 50% | 50% |
| TMD Treatment treatment for jaw and facial joint disorders | 50% | 50% |
Maximums and Deductible | ||
| Policy Year Maximum per member | $1,000 | $1,000 |
| Policy Year Deductible per member/per family *Deductible waived for these services | $50/$150 | $50/$150 |
Note: This policy provides DENTAL insurance only. The expected benefit ratio for this policy is 57.3 percent. This ratio is the portion of future premiums that the company expects to return as benefits, when averaged over all people on this policy.
NOTES: These summaries are samples of benefits. Policies have exclusions and limitations that may limit coverage. For complete coverage details, please refer to your policy, INVD-100A-[2016]-(state specific abbreviation, if applicable).
EXCLUSIONS: Cosmetic surgery or dentistry for aesthetic reasons (except reconstructive surgery for children because of congenital disease or anomaly); general anesthesia and/or intravenous sedation; treatment by anyone other than a licensed dentist or dental hygienist; veneers; sealants; prefabricated crowns as final restoration on permanent teeth and paste-type root canal filings 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 the 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 herein may not be available in all states or jurisdictions.