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Independence Dental – Coverage
Limits listed below apply per covered person.
Diagnostic Care Basic Care
• Bitewing X-rays, limited to one per calendar year
• Full-mouth X-rays, limited to one every three years • Simple extractions
• Fillings
Preventive Care
• Routine oral exams, limited »» Amalgam restorations
• Prophylaxis (the cleaning and scaling of teeth), »» Composite restorations, limited to anterior teeth
limited to two per calendar year and bicuspids
• Topical application of fluoride for dependent • Emergency palliative treatment to temporarily
children, limited to one per calendar year (this release pain
benefit may vary by dependent age and state
• Sealants, one per tooth every three years for Major Care
specific permanent molars (this benefit may vary by
dependent age and state) • Endodontic services
• Space maintenance, including the initial appliance • Periodontic services
and adjustments within six months of installation for • Oral surgery
a dependent child up to age 16 • Surgical extractions
• Dentures and maintenance prosthodontics
• Inlays, onlays and crowns
• Bridges
Eligibility Alternative benefits
Independence Dental is available to the primary If we determine that a less expensive service or supply
applicant age 18 to 99, his or her spouse age 18 to 99, and can be used in place of the proposed treatment based on
dependent children under the age of 26. broadly accepted standards of dental care, benefits are
limited to the maximum allowable charge for the least
Effective date expensive treatment. The maximum allowable charge is
determined by the in-network reimbursement schedule.
The plan will be effective the first of the month following
request for coverage, or a future selected effective date Pre-treatment estimate
not more than 60 days following enrollment. Due date for
payment will be the same as the effective date. Except in an emergency, before a covered person
may begin treatment that will cost more than the
Covered charges predetermination amount shown on the Schedule of
Benefits, the dentist must submit a claim to us describing
Expenses must be medically/dentally necessary and the treatment necessary and the cost. This estimate is not
incurred by a covered person while the plan is inforce. a guarantee of payment. We will still consider a claim for
A covered procedure must be performed by a licensed which the covered person has not obtained an estimate;
dentist acting within the scope of his or her license, a however, the claim may be subject to reduced benefits
licensed physician performing dental services within the based on our determination of the maximum allowable
scope of his or her license, or a licensed dental hygienist charge and medically necessary treatment.
acting under the supervision and direction of a dentist.
Coordination of benefits
This plan will be coordinated with any other group,
blanket or franchise plan under which an individual will
receive benefits. Coordinating benefits is not permitted in
all states.
Brochure Independence Dental Indemnity 0918 3
Limits listed below apply per covered person.
Diagnostic Care Basic Care
• Bitewing X-rays, limited to one per calendar year
• Full-mouth X-rays, limited to one every three years • Simple extractions
• Fillings
Preventive Care
• Routine oral exams, limited »» Amalgam restorations
• Prophylaxis (the cleaning and scaling of teeth), »» Composite restorations, limited to anterior teeth
limited to two per calendar year and bicuspids
• Topical application of fluoride for dependent • Emergency palliative treatment to temporarily
children, limited to one per calendar year (this release pain
benefit may vary by dependent age and state
• Sealants, one per tooth every three years for Major Care
specific permanent molars (this benefit may vary by
dependent age and state) • Endodontic services
• Space maintenance, including the initial appliance • Periodontic services
and adjustments within six months of installation for • Oral surgery
a dependent child up to age 16 • Surgical extractions
• Dentures and maintenance prosthodontics
• Inlays, onlays and crowns
• Bridges
Eligibility Alternative benefits
Independence Dental is available to the primary If we determine that a less expensive service or supply
applicant age 18 to 99, his or her spouse age 18 to 99, and can be used in place of the proposed treatment based on
dependent children under the age of 26. broadly accepted standards of dental care, benefits are
limited to the maximum allowable charge for the least
Effective date expensive treatment. The maximum allowable charge is
determined by the in-network reimbursement schedule.
The plan will be effective the first of the month following
request for coverage, or a future selected effective date Pre-treatment estimate
not more than 60 days following enrollment. Due date for
payment will be the same as the effective date. Except in an emergency, before a covered person
may begin treatment that will cost more than the
Covered charges predetermination amount shown on the Schedule of
Benefits, the dentist must submit a claim to us describing
Expenses must be medically/dentally necessary and the treatment necessary and the cost. This estimate is not
incurred by a covered person while the plan is inforce. a guarantee of payment. We will still consider a claim for
A covered procedure must be performed by a licensed which the covered person has not obtained an estimate;
dentist acting within the scope of his or her license, a however, the claim may be subject to reduced benefits
licensed physician performing dental services within the based on our determination of the maximum allowable
scope of his or her license, or a licensed dental hygienist charge and medically necessary treatment.
acting under the supervision and direction of a dentist.
Coordination of benefits
This plan will be coordinated with any other group,
blanket or franchise plan under which an individual will
receive benefits. Coordinating benefits is not permitted in
all states.
Brochure Independence Dental Indemnity 0918 3
