Page 2 - FL_Independence Dental Indemnity
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Your Bright Smile: A Reflection of Your Health
Dental insurance can help cover out-of-pocket expenses for exams and procedures, while
promoting more frequent visits, ultimately keeping you healthier. Independence Dental offers a
great plan for individuals and families.
Plan Design
Independence 1000 Independence Ultra 1500 Independence 1500
$20 None
Office Visit Copay $20 $50
(limit 1 per day) $50 $1,500
$1,500
Deductible $50 100%
100% 100%
Maximum benefit $1,000 100% 100%
(per covered person, per 100% 100%
calendar year) 100%
(calendar year deductible does 80%
Preventive Care: 100% not apply)
Exams 100% 80%
100% 100%
Cleanings 100% (calendar year deductible does
Topical fluoride (calendar year deductible not apply)
does not apply)
Sealants 80%
Diagnostic care: 100%
X-rays (calendar year deductible
does not apply)
Basic care: 50%
Fillings and extractions
Major care: 50% 50% 50%
Crowns, bridges,
dentures, root
canals, periodontics,
endodontics and oral
surgery
The amount of benefits provided depends on the plan selected and the premium will vary with the amount of benefits
selected.
Charges in excess of the Usual, Customary and Reasonable charge are the responsibility of the insured person. This
amount is the most common charge for treatment and services within your geographic area and is determined by the
insurance carrier based on claims data and a standard allowance level.
Coinsurance and waiting periods for diagnostic, basic and major vary by state.
Brochure Independence Dental Indemnity 0918 2
Dental insurance can help cover out-of-pocket expenses for exams and procedures, while
promoting more frequent visits, ultimately keeping you healthier. Independence Dental offers a
great plan for individuals and families.
Plan Design
Independence 1000 Independence Ultra 1500 Independence 1500
$20 None
Office Visit Copay $20 $50
(limit 1 per day) $50 $1,500
$1,500
Deductible $50 100%
100% 100%
Maximum benefit $1,000 100% 100%
(per covered person, per 100% 100%
calendar year) 100%
(calendar year deductible does 80%
Preventive Care: 100% not apply)
Exams 100% 80%
100% 100%
Cleanings 100% (calendar year deductible does
Topical fluoride (calendar year deductible not apply)
does not apply)
Sealants 80%
Diagnostic care: 100%
X-rays (calendar year deductible
does not apply)
Basic care: 50%
Fillings and extractions
Major care: 50% 50% 50%
Crowns, bridges,
dentures, root
canals, periodontics,
endodontics and oral
surgery
The amount of benefits provided depends on the plan selected and the premium will vary with the amount of benefits
selected.
Charges in excess of the Usual, Customary and Reasonable charge are the responsibility of the insured person. This
amount is the most common charge for treatment and services within your geographic area and is determined by the
insurance carrier based on claims data and a standard allowance level.
Coinsurance and waiting periods for diagnostic, basic and major vary by state.
Brochure Independence Dental Indemnity 0918 2
