|
MyPlan Options
Annual = calendar year |
80/50 Plan |
80/50/50 Plan |
100/50/50 Plan |
100/80/50 Plan |
|
Annual Maximum Benefit |
$750 |
$750 |
$750 |
$1,000 |
|
Dental Rewards®
and PPO Bonus |
Boost your annual
maximum by submitting at least one dental claim per year and keeping
your total paid claims for the year at or below $250. You will
“earn” a $125 reward to carry over toward your annual maximum the
next year. Earn rewards each year up to a
total of $500 in rewards. Where PPO is available, there's also a $50 bonus to
carry over if you see an Ameritas PPO provider. If no claims
are submitted during a year, no rewards are earned and accumulated rewards are
lost. But you can begin building rewards again the very next year. |
|
No waiting periods
if you were covered by another dental plan within 30 days of the
date we receive your application! See takeover benefits answer
on Q&A section for details |
|
Waiting Periods |
Preventive - none
Basic - 6 month |
Preventive - none
Basic - 6 month
Major - 12month |
Preventive - none
Basic - 6 month
Major - 12 month |
Preventive - none
Basic - 6 month
Major - 12 month |
|
Annual Dental Deductible per person |
$50 |
$50 |
$50 |
$50 |
| |
Coinsurance (plan pays*) |
|
Preventive (type 1)
 |
Exams
(twice per plan year)
|
|
|
Fluoride
Treatment for children under
|
age 14 (once per
plan year)
|
|
Bitewing
Films (once per plan year)
|
|
|
Full
Mouth Series or Panoramic x-ray
|
(once every 5 years) |
80% |
80% |
100% |
100% |
|
Basic (type 2)
|
|
Amalgams
& Resin Restorations
|
(Fillings)
|
|
Simple
Extractions |
|
|
Sealants
(under age 14) |
|
50% |
50% |
50% |
80% |
|
Major (type 3)
|
|
Space
Maintainers |
|
|
Root
Canals |
|
|
Surgical Endodontics
|
|
|
Periodontal
Procedures |
|
|
Surgical Extractions
|
|
|
General
Anesthesia |
|
|
Crowns |
|
Not covered |
50% |
50% |
50% |
|
Eye Care Benefit |
A $100 benefit
that you may use for exams, frames, lenses or contact lenses from
the eye care provider of your choice. In addition, if you
enroll in MyPlan, you will receive an eye care ID card that explains
how to access plan discounts. If you choose to use your eye
care benefit, it is deducted from the total annual maximum allowed
for dental benefits. If you use your plan's entire annual
maximum benefit for dental care, no eye care benefit will be
available that year. |
*Claim allowance, or plan payment, in network, all plans; When you visit an
Ameritas PPO network provider, the amount allowed for each covered
procedure is based on the maximum Allowable Charge (MAC). The MAC is
the network provider's contracted fee, derived and discounted from
the array of provider charges within a particular ZIP Code area.
It is reviewed and updated periodically to reflect increasing
provider fees within the ZIP Code area. You pay the difference
between the plan payment and the network dentist's contracted fee.
*Claim allowance, or plan payment, out of network, all plans: When you visit a
non-network provider, the amount allowed for each covered procedure
is based on the Maximum Allowable Benefit (MAB). The MAB is
derived from a blending and discounting of submitted provider
charges within a particular ZIP Code area. It is reviewed and
updated periodically to reflect increasing provider fees within the
ZIP Code area. You pay the difference between the plan payment
and the dentist's actual charge.
For a copy of the brochure, click here
Apply Online
Click here to Apply Online!
Replacement Form
(Online Version)
(If you are replacing other group coverage you can email
your certificate of credible coverage to
info@myplandental.com)
