Plan 1: Dental Plan Summary Effective Date: 9/1/2016



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Egyptian Area Schools Employee Benefit Trust

Dental Highlight Sheet





Plan 1: Dental Plan Summary Effective Date: 9/1/2016

Plan Benefit

High Plan

Low Plan

Type 1

100%

80%

Type 2

Type 3

80%

50%


70%

N/A





$50/Calendar Year Type 2 & 3

$50/Calendar Year Type 2

Deductible

Waived Type 1

Waived Type 1




3 Family Maximum

3 Family Maximum

Maximum (per person)

Allowance Type 1

Allowance Type 2

Allowance Type 3


$1500 per calendar year

90th U&C


Maximum Procedure Allowance

Maximum Procedure Allowance



$750 per calendar year

90th U&C


Maximum Procedure Allowance

None


Dental Rewards®

Included

Included

Ameritas Rewards SM

Included

N/A

Annual Eye Exam

None

None


Orthodontia Summary - Child Only Coverage

Allowance

U&C

No Ortho

Plan Benefit

50%




Lifetime Maximum (per person)

$1,000




Ameritas RewardsSM Lifetime (per person)

$100






Waiting Period

n/a





Sample Procedure Listing (Current Dental Terminology © American Dental Association.)

Type 1

Type 2

Type 3 (High Plan Only)

  1. Routine Exam

(2 per benefit period)

  1. Bitewing X-rays

(2 per benefit period)

  1. Full Mouth/Panoramic X-rays

(1 in 3 years)

  1. Periapical X-rays

  2. Cleaning

(2 per benefit period)

  1. Fluoride for Children 18 and under

(1 per benefit period)

  1. Sealants (age 16 and under)

  2. Space Maintainers

  3. Restorative Amalgams

  4. Restorative Composites

  5. Endodontics (nonsurgical)

  6. Endodontics (surgical)

  7. Periodontics (nonsurgical)

  8. Periodontics (surgical)

  9. Denture Repair

  10. Simple Extractions

  11. Complex Extractions

  12. Anesthesia

  1. Onlays

  2. Crowns

(1 in 5 years per tooth)

  1. Crown Repair

  2. Implants

  3. Prosthodontics (fixed bridge; removable complete/partial dentures)

(1 in 5 years)

U&C Disclosure

Usual and Customary (“U&C”) describes those dental charges that we have determined to be the usual and customary charge for a given dental procedure within a particular ZIP code area. U&C levels are based on experience from the Company and an independent outside source of claim charge information.



Maximum Procedure Allowance (WPA)

* With MPA, the plan allowance for each covered procedure is established according to the median dentist charges in the ZIP Code area where the services are provided.

* Keeps cost-conscious plan members from subsidizing those who use more expensive dentists.

* Reimbursement allowances automatically adjust if there’s an increase or decrease in the overall charges in the area..




Monthly Rates High Plan Low Plan

Employee Only (EE)

$32.08

$14.26

EE + 1 Dependent

$58.96

$26.18

EE + 2 or more Dependents

$85.70

$49.70



Ameritas RewardsSM (Feature with High Plan)

Ameritas Rewards is an enhanced product that offers an increased maximum for hearing, LASIK, orthodontia and vision as well as dental. It allows members to utilize unused dental maximum carryover amounts from previous years towards dental benefits or other lines of coverage included in a plan. Employees and their covered dependents may accumulate dental rewards with an unlimited maximum carryover amount. These rewards can be used to increase the maximum for the other lines of coverage which can then be used for certain covered services or materials subject to applicable deductible, coinsurance and plan provisions. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. A member is eligible to earn rewards again the next year.


Benefit Threshold

$750

Dental benefits received for the year cannot exceed this amount


Annual Carryover Amount

$250

Ameritas Rewards amount is added to the following year's maximum


Annual PPO Bonus

$150

Additional bonus is earned if the member sees a network provider


Maximum Carryover

Unlimited

Maximum possible accumulation for Dental Rewards and PPO Bonus combined




Dental Rewards® (Feature with Low Plan)

This dental plan includes a valuable feature that allows qualifying plan members to carryover part of their unused annual maximum. A

member earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or

under the threshold amount for benefits received for that year. Employees and their covered dependents may accumulate rewards up

to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable

coinsurance and plan provisions. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are

lost. But he or she can begin earning rewards again the very next year.

.


Benefit Threshold

$250

Dental benefits received for the year cannot exceed this amount


Annual Carryover Amount

$125

Dental Rewards amount is added to the following year's maximum


Annual PPO Bonus

$ 50

Additional bonus is earned if the member sees a network provider


Maximum Carryover

$500

Maximum possible accumulation for Dental Rewards and PPO Bonus combined




Dental Network Information

Both the High and Low Plan have the freedom to use any licensed dental provider. However, both plans include access to the Ameritas PPO Network. To find a provider, visit ameritas.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. Members utilizing a PPO provider may experience lower out of pocket costs due to negotiated fees with in-network providers



Questions?

Members can call 800-487-5553 or visit www.ameritas.com/group/olbc/egyptianschooltrust for plan information and online presentations. If already enrolled you may also use the www.ameritas.com website, members can select Account Access in the upper right hand corner to set up a user ID and password to check claim status, view detailed plan information, search for PPO providers and more


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