PPO Plan Highlights and Monthly Premiums
Individual $20.00
Individual + One $38.00
Individual + Family $60.00
BENEFIT YEAR MAXIMUM
| First Year
| Second Year
| Thereafter |
| Per Covered Person | $750
| $1,000 | $1,500 |
| | | | |
INSURANCE PERCENTAGE
| First Year
| Second Year
| Thereafter
|
Type I Covered Expenses - Preventative (Exams, cleanings, etc.)
| 100% | 100%
| 100%
|
Type II Covered Expenses - Basic (Fillings, Extractions, etc.)
| 80%
| 80%
| 80%
|
Type III Covered Expenses - Major (Crowns, Root Canals, Dentures, etc)
| 0%
| 50%
| 50%
|
| | | | |
WAITING PERIOD
| First Year
| Second Year
| Thereafter
|
Type III Covered Expenses
| 12 Months
| None | None |
| | (Unless prior)
| | |
| | | | |
BENEFIT YEAR DEDUCTIBLE
| First Year
| Second Year
| Thereafter
|
Type I - Per Covered Individual
| $50
| None
| None
|
Type II & Type III Combined- Per Covered Individual
| $50 | $50
| $50
|
|
| | |
Orthodontic - Participating Orthodontists ONLY
| | | |
Consultation Covered at 100%, Treatment Covered at 20% Discount
| | | |
To apply for dental coverage download and print application, complete information and include payment and send to address on application. *Policies must be paid through monthly bank draft (download form) or pay 6 months at a time.
Operating in Louisiana since 1978. Use any dentist or a
DINA DENTAL PPO Dentist.
*Usual, Reasonable and Customary charges may apply when accessing a dentist who is not participating in the network.
Important Notice These benefits are payable when using one of our Preferred Providers. If you choose another provider that does not participate with DINA Dental, you may incur additional charges. The Scheduled Charge is the maximum amount which benefits will be paid. A non-participating provider may charge more than the Scheduled Charge. If your dentist charges more than the Scheduled Charge, you will pay the deductible and co-insurance plus the amount over the Scheduled Charge.