Provision |
High Plan
In-Network |
High Plan
Out-of-Network |
Low Plan
In/Out-Network |
|
CO-INSURANCE LEVELS |
CO-INSURANCE LEVELS |
CO-INSURANCE LEVELS |
Class A — Preventive |
100% |
100% |
80% |
Class B — Basic |
90% |
80% |
50% |
Class C — Major |
60% |
50% |
50% |
Class D — Orthodontia |
50% Up to the lifetime maximum |
50% Up to the lifetime maximum |
50% Up to the lifetime maximum |
|
DEDUCTIBLES |
DEDUCTIBLES |
DEDUCTIBLES |
Class A — Preventive |
Waived |
Waived |
Waived |
Class B, C — Basic & Major |
$50
Maximum 3 per family = $150 |
$100
Maximum 3 per family = $300 |
$150
Maximum 3 per family = $450 |
Class D — Orthodontia |
Waived |
Waived |
Waived |
|
MAXIMUMS |
MAXIMUMS |
MAXIMUMS |
Class A, B, C, — Preventive, Basic & Major |
Annual maximum $1,500 |
Annual maximum $1,500 |
Annual maximum $1,000 |
Class D — Orthodontia |
$2,000 Lifetime maximum |
$2,000 Lifetime maximum |
$2,000 Lifetime maximum |
This is an abbreviated view of your dental plan highlights, for full details please download the dental plan highlights sheet.
The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. See the actual policy or your Unum representative for specific provisions and details of availability. Dental plans are marketed by Unum, administered and underwritten by Starmount Life Insurance Company, Baton Rouge, LA..