DENTAL PLAN

DIAMOND  1500

NO WAITING PERIODS

USE ANY DENTIST!!  

 

Benefit Maximum
Per person per policy year
$1,500
Deductible
Per person per policy year
$50
Max deductible per family   $150
Orthodontic Coverage
Lifetime max is $1000 for
Dependent children to age 18
  50%


SUMMARY OF BENEFITS

TYPE 1 – Diagnostic & Preventive       100%

Oral exams
Prophylaxis
Topical Fluoride

TYPE 2 – Basic Services                      65%

Simple Restorative
X-Rays
Sealants
Space Maintainers

 

TYPE 3 – Major Services           35%
Major Restorative
Bridge, Denture Repair
Prosthetics
Tooth Extraction
Endodontics
Periodontics

TYPE 4 – Orthodontia              50%

  

DIAMOND 1500   -     WITH ORTHO!!

Bi-Weekly Payroll Deduction

Individual

$19.00

Individual & one dependent

$32.00

Family

$55.00

 

 

Monthly Bank Draft

Individual

$41.17

Individual & one dependent

$69.33

Family

$119.17

 Providers:

Freedom to choose any dentist with claims paid at current UCR levels, or pick from one of our Dentemax providers for possible lower out of pocket costs.  You can access the Dentemax network at www.Dentemax.com

Disclaimer: Professional Benefit Administrators has no liability for providing or guaranteeing service and has no liability or responsibility for the quality of service rendered.

Frequently Asked Questions

How does the plan work?

1.           The indemnity plan allows you to seek treatment from any licensed dentist.

2.           Once services are performed, you or your dentist must file a claim form in order to receive reimbursement.

3.           Your claim will be paid based on your group’s certificate of coverage.  Benefits will be payable after your deductible and coinsurance (if applicable) are satisfied.  Your plan also has an annual limit on benefits available.

The dentist may agree to file your insurance claim for you. However, if he/she does not, you may be required to pay the entire bill at the time services are rendered and submit a claim to Citizens Security Life Insurance Company for reimbursement.

Where should I send my claims?

Claim forms can be obtained by calling   800-578-2082 and should be sent to:

Citizens Security Life Insurance Co.
Dental Claims Department
P. O. Box 436149
Louisville, KY 40253-6149

or

Faxed: 502-254-4077

What is a predetermination?

The purpose of submitting a predetermination is to help you understand how your benefits will be paid for your proposed treatment plan.

When is a predetermination needed?

If a planned treatment is going to cost over $200, you should ask the dentist to file for predetermination of benefits before services begin.