Ohio - overview and prepayment fees. Please note this is not a discounted dental plan, as some may offer, but a full dental plan offered as a HMO through a chosen Dentist whom you choose through the dental provider network.

Secure Choice

The Secure Choice plan provides dental benefits with attractive prepayment fees.  To receive the benefits of the Secure Choice plan, you will need to select a Plan Dentist for you and your family members from the list of dentists. You may choose a different dentist for each family member.

Features of the Secure Choice Plan:

§                    No deductibles

§                    No claim forms

§                    No annual maximum

§                    Fixed co-payment schedule for Plan Dentists

§                    Reduced fees on Orthodontic procedures for children and adults

§                    No referral required for Specialist benefits

§                    Benefits for pre-existing dental conditions

Prepayment fee options *

Or you may choose the

Automatic Monthly Bank Draft

Accounts are drafted on the 15th of each month prior to the month of benefits.
A monthly administration charge is included in the fees below.

Individual

$12.24

Individual & One Dependent

$19.84

Family

$30.57

 

$35.00 Enrollment Fee

Annual Prepayment Fees

Individual

$131.82

Individual & One Dependent

$223.08

Family

$351.86

 

Ohio - sample co-payments. Please note your specific Dental Service Agreement for your specific benefits and limitations.

Secure Choice

The following is a sample of some frequently used dental procedures. When you enroll for the plan, you will pay reduced fees called co-payments. These reduced fees are only available from providers who participate in our network. After you enroll, a complete list of co-payments will be mailed to your home along with your Individual Dental Service Agreement. The sample below demonstrates potential savings with the Secure Choice plan and may not reflect your actual results.

Dental Treatment

With Secure Choice

Average Retail Charges†

Appointments

 

 

 

Periodic Oral Evaluation

No Charge

$31

 

Limited Oral Exam

$25

$46

 

Comprehensive Oral Evaluation

No Charge

$49

Diagnostic Dentistry

 

 

 

Complete X-Ray Series, Including Bitewings

$10

$89

Preventive Dentistry

 

 

 

Routine Cleaning - Adult (once every 6 mos.)

$10

$60

 

Routine Cleaning - Child (once every 6 mos.)

$10

$42

 

Application Of Fluoride (up to 18 years of age)

No Charge

$24

 

Oral Hygiene Instruction

No Charge

$29

 

Application Of Sealant, Per Tooth

$20

$34

 

Fixed Space Maintainer

$85*

$217

Fillings/Crowns

 

 

 

Silver Fillings

 

 

 

 

One Surface

$25

$77

 

 

Two Surfaces

$30

$95

 

 

Three Surfaces

$45

$114

 

White Fillings

 

 

 

 

One Surface, Anterior

$50

$95

 

 

Two Surfaces, Anterior

$65

$118

 

 

Three Surfaces, Anterior

$80

$143

 

 

One Surface, Posterior

$85

$107

 

 

Two Surfaces, Posterior

$100

$140

 

 

Three Surfaces, Posterior

$105

$171

 

 

Crowns - Porcelain To High Noble Metal

(cost of precious & semi-precious metal is additional)

$295*

$753

 

 

Core Buildup

$55

$168

Root Canals

 

 

 

 

Anterior

$145

$484

 

 

Bicuspid

$225

$574

 

 

Molar

$295

$724

Periodontics

 

 

 

Periodontal Scaling And Root Planing, Per Quadrant

$90

$166

 

Full Mouth Debridement (complicated cleaning)

$90

$106

Dentures

 

 

 

Complete Denture - Upper

$385*

$864

 

Complete Denture - Lower

$385*

$851

 

Partial Denture - Upper

$410*

$580

 

Partial Denture - Lower

$410*

$768

Oral Surgery

 

 

 

Single Tooth Extraction

$25

$77

 

Removal Of Impacted Tooth

 

 

 

 

Soft Tissue

$105

$206

 

 

Partial Bony

$140

$268

 

 

Complete Bony

$165

$311

 

 

Complete Bony with complications

$205

$361

Orthodontics

 

 

 

Orthodontic treatment for children and adults is provided at a 25% reduction from Plan Specialist's normal retail charges.

*  The Plan Dentist you select may not perform all procedures listed.  The co-payments shown apply to those Plan Dentists who perform those services. Therefore, you are encouraged to discuss availability of the scheduled services with your Plan Dentist. Charges for procedures not listed on the Co-payment Schedule that are performed by your Plan Dentist are not covered under the Secure Choice Plan.

Should you require dental services that your selected Plan Dentist is unable to provide, you may obtain those services from a Plan Specialist at a reduced rate.  No referral is needed from your Plan Dentist in order for you to obtain services from a Plan Specialist.  There is no applicable co-payment schedule for Plan Specialist services.  Instead, the following reductions off the Plan Specialist's normal retail charges apply to all services received from a Plan Specialist.  A 15% reduction applies if the Plan Specialist is an endodontist.  A 25% reduction applies if the Plan Specialist is any other type of specialist, including but not limited to an orthodontist.  You are responsible for paying the entire reduced charge at the time the service is received, or in accordance with the Plan Specialist's billing procedures.

Payment for each service of a Non-Plan Dentist or Non-Plan Specialist (at the provider's normal retail charge) is your responsibility, except for limited Plan Benefits for covered dental Emergency Services for temporary pain relief.

* Members are responsible for additional lab fees for these services.

·        The Average Retail Charges were determined by Assurant Employee Benefits claims analysis for the year 2003 and are adjusted annually as the market changes.  The Retail Charges represent a mean average rounded to the nearest dollar representing what you may pay without the plan services and are given as a sample only.  After you have enrolled, a complete list of your specific dental co-payments will be sent to your home with your Dental Service Agreement.

·        Please refer to your specific Dental Service Agreement for a complete explanation of your benefits and limitations.  The above information is given to assist persons with a general understanding of this program and is not designed to be complete in its coverage of benefits and limitations.