Page 2 - FL_Independence Dental PPO
P. 2
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 PPO plan for individuals and families.
Plan Design
Independence PPO 1000 Independence Ultra PPO 1500 Independence PPO 1500
Office visit copay $20 $20 None
(limit 1 per day)
Deductible $50 $50 $50
Maximum benefit $1,000 $1,500 $1,500
(per covered person, per
calendar year)
Preventive Care: 100%/100% 100%/100% 100%/100%
100%/100% 100%/100% 100%/100%
(In-Network/Out-of-Network) 100%/100% 100%/100% 80%/80%
100%/100% 100%/100% 80%/80%
Exams (calendar year deductible (calendar year deductible does
Cleanings does not apply) not apply)
Topical fluoride
Sealants
Diagnostic care: 100%/100% 100%/100% 80%/80%
X-rays (calendar year deductible (calendar year deductible does
does not apply) not apply)
Basic care: 50%/50% 80%/80% 80%/80%
Fillings and extractions
Major care: 50%/50% 50%/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.
When utilizing in-network dental providers:
Network providers have agreed to a negotiated, discounted dollar amount for each covered charge. Therefore, if all
dental services are received from network providers, you will not be billed for any charges above the allowed amount,
or maximum allowable charge.
When utilizing out-of-network providers:
If you receive dental services from a provider that is not included in the network, covered expenses are limited to the
maximum allowable charge.* You will receive a bill from the provider if out-of-network expenses exceed the maximum
allowable charge.
The PPO network available with Independence Dental varies by state. Please refer to the provider directory for a
complete list of available network dental providers in your area.
Coinsurance and waiting periods for diagnostic, basic and major vary by state. *Not available in all states.
Brochure Independence Dental PPO 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 PPO plan for individuals and families.
Plan Design
Independence PPO 1000 Independence Ultra PPO 1500 Independence PPO 1500
Office visit copay $20 $20 None
(limit 1 per day)
Deductible $50 $50 $50
Maximum benefit $1,000 $1,500 $1,500
(per covered person, per
calendar year)
Preventive Care: 100%/100% 100%/100% 100%/100%
100%/100% 100%/100% 100%/100%
(In-Network/Out-of-Network) 100%/100% 100%/100% 80%/80%
100%/100% 100%/100% 80%/80%
Exams (calendar year deductible (calendar year deductible does
Cleanings does not apply) not apply)
Topical fluoride
Sealants
Diagnostic care: 100%/100% 100%/100% 80%/80%
X-rays (calendar year deductible (calendar year deductible does
does not apply) not apply)
Basic care: 50%/50% 80%/80% 80%/80%
Fillings and extractions
Major care: 50%/50% 50%/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.
When utilizing in-network dental providers:
Network providers have agreed to a negotiated, discounted dollar amount for each covered charge. Therefore, if all
dental services are received from network providers, you will not be billed for any charges above the allowed amount,
or maximum allowable charge.
When utilizing out-of-network providers:
If you receive dental services from a provider that is not included in the network, covered expenses are limited to the
maximum allowable charge.* You will receive a bill from the provider if out-of-network expenses exceed the maximum
allowable charge.
The PPO network available with Independence Dental varies by state. Please refer to the provider directory for a
complete list of available network dental providers in your area.
Coinsurance and waiting periods for diagnostic, basic and major vary by state. *Not available in all states.
Brochure Independence Dental PPO 0918 2
