RoanokeCollege
Dental Benefits
Low Plan
Coinsurance (Plan Pays)
Preventive Procedures...... 100%*
Exams (2 per benefit period), cleanings (2 per benefit period), x-rays, fluoride for children (under age 19), sealants (under age 17), space maintainers and other procedures
Basic Procedures...... 80%*
Fillings, simple extractions, anesthesia, oral surgery, root canals, gum disease and other procedures
*Usual, Customary and Reasonable charge. This plan utilizes the 90th percentile of UCR, which means 9 out of 10 dentist’s charge at or below the amount we allow for a particular procedure. The ZIP code of your dental provider is used in determining allowances.
Deductible Amounts
Preventive Procedures
Deductible Waived for Preventive Procedures...... $0
BasicProcedures (3 Family Max)
Calendar Year-Per Person...... $50
Maximum
Preventive and Basic Procedures
Calendar Year-Per Person...... $1000***
Carry Over Amount-Per Person-Each Benefit Period………………………$250
Benefit Threshold-Per Person-Each Benefit Period………………………...$500
Maximum Carry Over Amount……………………………………………..$1000
(Dental Rewards-Annual Maximum Carry Over)
***To qualify for Dental Rewards:
- Visit a dentist between January 1 and December 31 of each year.
- Submit a claim for a covered procedure prior to March 1 of the following year.
- Total Benefits reimbursed by Ameritas for the calendar year are $500 or less.
If you meet all three requirements, you will be eligible for the Annual Maximum Carryover benefits. This benefit will provide you with an additional $250 towards your annual dental maximum for the following year. In future years, if you continue to meet these requirements, you will continue to see an added amount in your annual maximum by $250 until you have reached an annual maximum carry over of $1000. This benefit can allow you to accumulate to a $2000 dental maximum!
Late Entrant (Applies to both High & Low Plan)
If an employee or dependent does not elect to participate when initially eligible, and elects to participate at the policyholder’s next annual election period, they will become a Late Entrant. Late Entrant benefits will be limited to exams, cleanings and fluoride applications for the first 12 months. The Late Entrant is waived only if the insured comes on the plan as a result of a qualifying event.
This form is a benefit highlight, not a certificate of insurance.
...The Dental Health Experts
RoanokeCollege
Dental Benefits
High Plan
Coinsurance (Plan Pays)
Preventive Procedures...... 100%*
Exams (2 per benefit period), cleanings (2 per benefit period), x-rays, fluoride for children (under age 19), sealants (under age 17), space maintainers and other procedures
Basic Procedures...... 80%*
Fillings, simple extractions, anesthesia, oral surgery, root canals, gum disease and other procedures
Major Procedures...... 50%*
Crowns, dentures, bridges and other procedures
Orthodontia Procedures...... 50%*
*Usual, Customary and Reasonable charge. This plan utilizes the 90th percentile of UCR, which means 9 out of 10 dentist’s charge at or below the amount we allow for a particular procedure. The ZIP code of your dental provider is used in determining allowances.
Deductible Amounts
Preventive Procedures
Deductible Waived for Preventive Procedures...... $0
Basicand Major Procedures (3 Family Max)
Calendar Year-Per Person...... $50
Orthodontia Procedures (Adult & Child)
Deductible Waived for Orthodontia Procedures...... $0
Maximum
Preventive, Basic and Major Procedures
Calendar Year-Per Person...... $1000***
Carry Over Amount-Per Person-Each Benefit Period………………………$250
Benefit Threshold-Per Person-Each Benefit Period………………………...$500
Maximum Carry Over Amount……………………………………………..$1000
(Dental Rewards-Annual Maximum Carry Over)
***To qualify for Dental Rewards:
- Visit a dentist between January 1 and December 31 of each year.
- Submit a claim for a covered procedure prior to March 1 of the following year.
- Total Benefits reimbursed by Ameritas for the calendar year are $500 or less.
If you meet all three requirements, you will be eligible for the Annual Maximum Carryover benefits. This benefit will provide you with an additional $250 towards your annual dental maximum for the following year. In future years, if you continue to meet these requirements, you will continue to see an added amount in your annual maximum by $250 until you have reached an annual maximum carry over of $1000. This benefit can allow you to accumulate to a $2000 dental maximum!
Orthodontia Procedures (Adult & Child)
Lifetime-Per Person...... $1000