|
Zip Codes |
Member Only |
Member +1 |
Member +2 or more |
|
754-759, 768, 779-781, 786, 788,
790-796, 798-799 |
$20.00 |
$42.00 |
$57.00 |
|
753, 761-767, 769, 773, 776-777, 782-785, 797 |
$21.00 |
$44.00 |
$60.00 |
|
750-751, 760, 774, 778, 787, 789 |
$23.00 |
$48.00 |
$65.00 |
|
752, 770-772, 775 |
$26.00 |
$52.00 |
$72.00 |
Add:
- Association Fees - $2.00 monthly
- Initial Enrollment Fee - $10 (one time)
- Billing Fee - Does not apply for Monthly
Bank Draft (see
application, page 2)
Services &
Benefits: Select Dental Insurance Plan
|
Deductible |
Plan Pays* |
Dental Services Covered |
$10 per
visit
$20 maximum
per benefit year |
80% |
Type 1 - Diagnostic and Preventative
Treatment
Diagnostic: Routine periodic examinations once in a
six month period
Preventative: Dental prophylaxis - teeth
cleaning and scaling - once in a six month period (including
application of topical fluoride for dependent children under
age 14 only) |
$50
per benefit year
(once paid, also satisfies major
services deductible) |
80% |
Type 2 - Basic Procedures (3
month waiting period)
Radiography: Bitewing x-rays once in a six month
period. Full mouth x-rays once in a 36 month period.
Palliative: Emergency treatment for relief of
pain
Restorative: Amalgam, synthetic porcelain, or
plastic fillings
Other: Space maintainers, recementation of
crowns |
$50
per benefit year
(once paid, also satisfies major
services deductible) |
50% |
Type 3 - Major Procedures
(12 month waiting period)
Endodontics: Pulpal therapy and root canals
Oral Surgery: Extractions and other oral
surgery; including pre and post operative care
Periodontics: Treatment of diseases of the gums
Prosthetics: Initial placement of crowns,
bridges, partial and complete dentures
Other: Pontics,repair of crowns and bridges,
full and partial dentures, repair. |
|
Diagnostic x-rays and teeth cleanings as follows:
Full mouth x-rays once every 36 months; bitewing x-rays and
prophylaxis once every 6 months; topical fluoride treatment
(dependent children under age 14) once every six months.
Benefits are based upon reasonable and customary charges for
the areas where expenses are incurred.
*There is a 3-month
waiting period for Type 2 Basic Procedures from the insured
person's
effective date of coverage.
**There is a 12-month waiting period for Type 3
Major Procedures from the insured person's
effective date of
coverage.
***There is a 24-month waiting period for replacement of
Prosthetic Appliances (crowns, bridges,
dentures). |
*Dental Insurance Benefits are based on
reasonable and customary charges for the areas where expenses are
incurred.
Call us for additional
information:
Houston TX Metro: 713-932-9072
Toll Free - TX & Nationwide : 1-888-777-0474
www.InsTexas.com
|
