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Individual Dental Insurance


Preventive & Diagnostic Services
*Coverage* One initial examination per calendar year Two prophylaxis (cleaning) per calendar year
	*Preferred Provider* Pays 100% of PPO $50 annual deductible* No waiting period	*Non-Preferred Provider* Pays 80% of U&C $50 annual deductible No waiting period

Basic Restorative Services
*Coverage* Bitewing x-rays, two per calendar year One fluoride treatment per calendar year for dependents under age 16 Simple restorative services (fillings)
	*Preferred Provider* Pays 70% of PPO $50 annual deductible* 6-mo. waiting period	*Non-Preferred Provider* Pays 50% of U&C $50 annual deductible 6-mo. waiting period

Major Services
*Coverage* Oral surgery Bridge Periodontics		Crown Endodontics
	*Preferred Provider* Pays 50% of PPO $50 annual deductible* 18-mo. waiting period	*Non-Preferred Provider* Pays 50% of U&C $50 annual deductible 18-mo. waiting period

* Combined Preventive, Basic and Major calendar year deductible maximum is $150 per family. combined calendar year maximum benefit amount for Preventive, Basic and Major is $1,000 per Person.

Note: This is a general outline of covered benefits and does not include all the benefits, limitations, and exclusions of the policy. See your certificate for details.

Claims will not be applied to your deductible until the applicable waiting period has been met.

Rate Schedule (monthly)	Minnesota Region
• Single	$28.33
• Single + 1	$53.12
• Single + Family	$80.74

Rates are effective April 1, 2005. Premiums are subject to change with 30 days notice.

Click here to Find a Preferred Provider Dentist
(Choose find a dentist, use the Premier Classic network)

Apply Online - Click Here

Print an Application - Click Here