| PPO Plan In-Network | Plan A | Plan B | |
|---|---|---|---|
| Annual maximum benefit for preventive, basic and major covered services | $2,000 per person | $1,250 per person | $1,000 per person |
| Late Entrant Provision (see definition here) | Applies | Applies | Applies |
| Preventive:All three plans cover: | |||
| 2 routine exams per year2 routine prophylaxis (cleanings) per yearSpace maintainersX-raysFluoride treatments for children under age 19 | No deductible Covered in full up to the MAC1. | No deductible Covered in full up to U&C2. | No deductible Pays a predetermined fixed amount3 based on procedure received. |
| Basic:All three plans cover: | |||
| FillingsSealantsFull or partial denture repairAnesthesia for oral surgeryRemoval of teeth | No deductible; Reimbursement at:80% of MAC1 during first year of coverage90% of MAC1 during second year of coverage if a covered procedure is received during the first year100% of MAC1 thereafter if a covered procedure is received in the second and following years | After $100 lifetime deductible per person; Reimbursement at:80% of U&C2 during first year of coverage90% of U&C2 during second year of coverage if a covered procedure is received during the first year100% of U&C2 thereafter if a covered procedure is received in the second and following years | After a combined basic and major annual deductible of $50 per person, the plan pays a predetermined fixed amount3 based on procedure received. |
| Major:All three plans cover: | |||
| CrownsBridgeworkPartial or full denturesDentures, prosthodontics, and inlaysPeriodontal maintenance (periodontal cleaning) and gum treatmentEndodontic procedures (root canals, etc.) | After a $50 calendar year deductible per person; Reimbursement at:50% of MAC165% of MAC1 for periodontic or gum treatment65% of MAC1 for endodontic procedures | After a $75 calendar year deductible per person; Reimbursement at:50% of U&C265% of U&C2 for periodontic or gum treatment65% of U&C2 for endodontic procedures | After a combined basic and major annual deductible of $50 per person, the plan pays a predetermined fixed amount3 based on procedure received. |
| Orthodontia: | |||
| All three plans cover orthodontia only if treatment begins after the participant becomes covered by a Duke Dental Plan. | No deductible. 50% of U&C2 $1,000 lifetime orthodontia maximum benefit per person (adults and children) | No deductible. 50% of U&C2 $1,000 lifetime orthodontia maximum benefit per person (adults and children) | No deductible. 50% of U&C2 $750 lifetime orthodontia maximum benefit per person (adults and children) |
- All payments are based on the Maximum Allowable Charges (MAC). PPO dentists have agreed to accept the contracted fee (MAC) as the maximum charge.
- All payments are based on the usual and customary (U&C) allowable charge. You are responsible for charges over U&C.
- The fee schedule, or reimbursement for each type of dental procedure, is available on the Ameritas website at ameritas.com.
