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Not all coverage is the right coverage.

Your healthcare coverage is important to us. Age, family status, medical conditions, hobbies, lifestyle and a myriad of other factors will help you determine if you need a lot or a very little amount of health coverage. This summary will help you understand your plan and its coverage.

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Summary of Medical Benefits

Copay Plan

In-Network

Out-of-Network

Embedded Deductible

Individual

Individual under Family

Family

 

$500

$500

$1,000

 

$3,000

$3,000

$6,000

Embedded Out-of-Pocket Maximum

Individual

Individual under Family

Family

 

$1,000

$1,000

$2,500

 

$5,000

$5,000

$12,500

Preventive Care Services

No Charge

Not Covered

Frames/Lenses/Contacts (Ages 19+)

Two pair each Deductible year

$750 Maximum per Deductible year

 

No Charge

 

 

No Charge

 

Frames/Lenses/Contacts (Ages 0 through 18)

Two pair each Deductible year

 

No Charge

 

No Charge

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

$20 Copay

$40 Copay

$40 Copay

30%* After Deductible

30%* After Deductible

30%* After Deductible

Urgent Care Services

$50 Copay

$50 Copay

Complex Imaging: MRI/CT/PET Scans

KIS Imaging: No Charge; Non-KIS Imaging: 10% Coinsurance After Deductible

KIS Imaging: No Charge; Non-KIS Imaging: 30% Coinsurance After Deductible

Inpatient Hospital Care

Facility Fee

Physician Fee

 

$250 Copay per confinement, then 10% Coinsurance After Deductible

10%* After Deductible

 

$500 Copay per confinement, then 30% Coinsurance After Deductible

30%* After Deductible

Outpatient Procedures

Facility Fee

Physician Fee

 

$250 Copay per procedure, then 10% Coinsurance After Deductible

10%* After Deductible

 

$500 Copay per procedure, then 30% Coinsurance After Deductible

30%* After Deductible

Emergency Room Services

Emergency Medical Transportation

$100 Copay, Waived if admitted

10%* After Deductible

$100 Copay, Waived if admitted

10%* After Deductible

Mental Health/Chemical Dependency

Inpatient

Office Visit

Behavior Therapy Treatment

 

10%* After Deductible

$20 Copay

$20 Copay

 

30%* After Deductible

30%* After Deductible

30%* After Deductible

Summary of Pharmacy Benefits

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

 

$5 Copay

$15 Copay

$35 Copay

$50 Copay

Mail Order 90 Day Supply

 

$5 Copay

$15 Copay

$35 Copay

$50 Copay

*Coinsurance

 

 

Dental Plan Benefit Summary

Dental Plan Benefits Summary

Dental Deductible

Individual

Family

 

$50

$150

Maximums

Deductible Year Maximum Benefit Per Person Age 19 and Over (Excluding Orthodontia)  

Lifetime Maximum Benefit For Orthodontia (Coverage for participants up to age 26) 

 

$2,500

$1,500

Class I-Diagnostic and Preventive Procedures 

Oral Examination (Limited to one time in any six consecutive month period )

Bitewing X-rays (Limited to one set in any 12 consecutive month period , Maximum of four films per set) 

Dental Prophylaxis or Periodontal Maintenance Procedure  (Limited to one time in any six consecutive month period )

Fluoride Treatments  (Limited to one time in any 12 consecutive month period for covered Dependent children under the age of 14)

Space Maintainers (Limited to Covered Dependent children under the age of 14)

Sealants (Limited to the occlusal surface of a permanent posterior tooth for covered Dependent children under age 14, once per lifetime of tooth )

Vizilite (Oral Cancer Screening) 

No Charge

 

 

 

 

 

 

 

 

 

 

 

 

 

Class II-Basic Procedures and Diagnostic Services 

Complete Series or Panorex (Limited to one time in any 60 consecutive month period - ten or more individual periapical x-rays and/or bitewing films will be considered a complete series for benefit purposes )

Individual Periapical X-Rays  (Limited to four periapical x-rays which are not performed in conjunction with an operative procedure in any 12 consecutive month period )

Intraoral Occlusal X-Rays (Limited to two films in any 12 consecutive month period)

15%* After Deductible  

 

 

 

 

 

Fillings

Restorations (Amalgam, Silicate, or Composite Resin)  (Replacement of an existing restoration is only payable if at least 12 consecutive months have passed since the existing filling was placed )

Pin Retention (Limited to one time per restoration, regardless of the number of pins used, only in conjunction with amalgam or composite restorations)

15%* After Deductible  

 

 

 

Oral Surgery, Routine Extractions  

Simple Extractions 

Root Removal 

15%* After Deductible  

 

 

Miscellaneous Services 

Palliative Treatment (Paid as a separate benefit only if no other service, except x-rays, was rendered during the visit)

15%* After Deductible  

 

Minor Periodontal Procedures 

Periodontal Scaling and Root Planing (Limited to one time per quadrant in any 36 month period – not covered if performed in conjunction with prophylaxis)

Periodontal Maintenance following Active Therapy (Covered once in any six month period if at least six months have passed since periodontal surgery)

15%* After Deductible  

 

 

 

Major Periodontal Surgery 

Gingivectomy (Gingival Flap Procedure- including root planning) (Covered only when performed in connection with periodontal surgery - limited to one time per area of the mouth in any 36-month period)

Mucogingival Surgery (per quadrant) 

Osseous Surgery 

Clinical Crown Lengthening  

Bone Replacement Graft 

Guided Tissue Regeneration (Restorable barrier per site, per tooth - limited to one time per area of the mouth in any 36 month period.  This benefit is not covered is performed during the same operative session in the same site as osseous surgery )

Soft Tissue Graft 

Distal or Proximal Wedge Procedure 

15%* After Deductible  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oral Surgery – Surgical Extractions 

Surgical Extraction 

Surgical Removal of Residual Tooth Roots 

15%* After Deductible  

 

 

Class III – Major Procedures and Diagnostic Procedures 

Histopathologic Exam 

50%* After Deductible 

 

Denture Adjustments, Rebasing and Relining 

Denture Adjustments (Limited to adjustments once in any 12 month period and only if performed more than 12 months after the initial installation)

Relining & Rebasing Dentures (Limited to relining or rebasing done more than 12 months after initial installation and then not more than one time in any 36 month period)

Tissue Conditioning (Maxillary or mandibular – covered only if at least 12 months have passed since initial installation and only once in any 36 month period)

50%* After Deductible 

 

 

 

 

 

Repairs to Crowns and Inlays  

Re-cement Inlays 

Re-cement Crowns 

Repairs to Crowns (Limited to repairs performed more than 12 months after initial installation)

50%* After Deductible 

 

 

 

Repairs to Dentures and Bridges 

Denture Repairs (Limited to repairs performed more than 12 months after the initial installation)

50%* After Deductible 

 

Inlays, Onlays, and Crowns 

Inlays, Onlays, and Crowns (Covered only when the tooth cannot be restored by an amalgam or composite filling due to major decay or fracture and then only if more than 84 months have passed since last placement )

Stainless Steel or Resin Based Crown  (Covered only when the tooth cannot be restored by a filling once in any 36 month period for covered Dependent children age 15 and under )

Post and Core (In conjunction with a crown or inlay- Covered only for teeth that have had root canal therapy)

50%* After Deductible 

 

 

 

 

 

Endodontic Procedures 

Pulpotomy  (Limited to deciduous teeth only )

Root Canal Therapy (Retreatment is covered only if more than 24 months have passed since initial installation )

Apexification (Limited to three visits per tooth)

Apicoectomy/Retrograde Filling/Root Amputation 

Hemisection (Includes local anesthesia and routine postoperative care.  Fixed bridgework replacing the extracted portion is not covered )

50%* After Deductible 

 

 

 

 

 

 

 

 

 

Other Oral Surgery 

- Implants (Including any appliances and/or crowns and the surgical insertion or removal )

- Tooth Transplantation  

- Surgical Exposure of Impacted or Unerupted Tooth to Aid Eruption 

- Biopsy 

- Alveoloplasty 

- Vestibuloplasty  (Covered only when performed primarily to facilitate insertion of a removable denture )

- Radical Excision of Reactive Inflammatory Lesions 

- Removal of a Cyst or Tumor  

- Removal of Exostosis 

- Incision and Drainage 

- Osseous, Osteoperiosteal, or Cartilage Graft of the Mandible or Facial Bones  (Covered only when performed primarily to facilitate insertion of a removable denture) 

- Vestibuloplasty (Covered only when performed primarily to facilitate insertion of a removable denture)

- Frenectomy 

- Excision of Hyperplastic Tissue 

- Excision of Pericoronal Gingiva 

- Synthetic Graft (Covered only when performed primarily to facilitate insertion of a removable denture)

50%* After Deductible 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Surgical Extraction of Impacted Teeth 

Surgical Removal of Impacted Tooth (Soft Tissue, Partially Bony, Completely Bony) 

Removal if Impacted Tooth (Completely Bony) with Unusual Surgical Complications 

50%* After Deductible 

 

 

Prosthetics 

Full Dentures (Limited to one time per arch each 84 month period)

Partial Dentures (Limited to one time per arch each 84-month period unless there is a necessary extraction of an additional functioning natural tooth )

Add Tooth to Existing Partial Denture to Replace Newly Extracted Functional Natural Tooth (Covered only if more than 12 months have passed since initial installation)

Post and Core (in conjunction with a fixed bridge- Covered only for endodontically treated teeth which total loss of tooth structure)

Fixed Partial Denture, Replacement (Replacement of an existing bridge are covered only if 84 months have passed since initial installation )

Prosthesis Over Implant (Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is only payable if performed more than 84 months after initial installation)

50%* After Deductible 

 

 

 

 

 

 

 

 

 

 

 

Anesthesia and IV Sedation 

General Anesthesia/IV Sedation  (Will be paid as a separate procedure when administered in conjunction with complex oral surgical procedures) 

50%* After Deductible 

 

Orthodontia 

This is treatment to move teeth by means of appliances, to correct a handicapping malocclusion of the mouth. Services include preliminary study and treatment plan, x-rays, diagnostic casts, active treatment and retention appliance. Payments for comprehensive full-banded orthodontic treatments are made in installments. 

50%* After Deductible 

 

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