Benefits as of 03/13/2022
Ameritas Life Insurance Corp The benefit information listed below is general plan
P.O. Box 82520 information and is subject to all policy provisions and
Lincoln, NE 68501-2520 limitations. Final benefit calculation will be determined upon
1-800-487-5553 / New Claims Fax # 402-467-7336 receipt of the claim. This is not a guarantee of payment or
Electronic Payer ID 47009 eligibility. For more specific information, please provide a
pre-treatment estimate.
Plan Member: YEN,SHIH-HSIANG
Plan Number: 0-2507-52925
Plan Sponsor:
Coverage Status Information: plan member
Late Entrant:
Missing Teeth: No benefits payable for the initial placement of any prosthetic or fixed bridge unless the
placement is made necessary by the extraction of one or more natural teeth while
insured.
General Plan Information
The member will receive a discounted fee for covered services by utilizing a network provider.
Benefit Period: insured benefit year: The plan benefit period begins on the plan member's individual
effective date.
Benefit Type/Plan Benefit: Elimination Period:
Type 1 - Preventive 90% MAB None
100%
Type 2 - Basic 50% MAB None
80%
Type 3 - Major 15% MAB 12 months
15%
* Plan Benefit advances each succeeding benefit period. Starting plan benefit levels may vary depending upon the individual
effective date and plan provisions.
MAB – Maximum Allowable Benefit. Benefits out of network are based on contracted provider fees in the area.
Deductibles: $50 Type 2, Type 3 Annual Combined
Family Maximum Deductible: 3 Family Members Annual
Maximum Annual Benefit: $750 per individual
With this plan, benefits for covered Type 1 - Preventive dental procedures are not deducted from the
maximum annual benefit.
Orthodontics: There is no orthodontic coverage under this plan.
Benefit Period: Please Note: The service categories and plan
Insured Benefit Year: The plan benefit limitations shown represent an overview of
period begins on the plan member's your plan benefits. The summary represents
individual effective date. the majority of services within each category
and coverage may vary depending on
procedure code and whether the service is
covered.
Service Benefit Type Frequency Contributing Additional Information
Procedures
Exams
Comprehensive Type 1 - Preventive 2 per D0120 D0145
Exam benefit D0150 D0180
period
Routine Exam Type 1 - Preventive 2 per D0120 D0145 Procedure D0120 will be considered for
benefit D0150 D0180 individuals age 3 and over. Procedure D0145
period will be considered for individuals age 2 and
under.
Problem Focused Not Covered
Exam
Prophylaxis (Cleanings)
Prophylaxis Type 1 - Preventive 2 per D1110 D1120 An adult prophylaxis (cleaning) is considered
(Cleanings) benefit for individuals age 14 and over. A child
period prophylaxis (cleaning) is considered for
individuals age 13 and under. Benefits for
prophylaxis (cleaning) are not available when
performed on the same date as periodontal
procedures.
Fluoride Type 2 - Basic 1 per D1206 D1208 To age 16.
benefit
period
Periodontal Type 3 - Major 2 per D4346 D4910 Benefits are not available if performed on the
Maintenance benefit same date as any other periodontal service.
period Procedure D4910 is contingent upon evidence
of full mouth active periodontal therapy.
Procedure D4346 is limited to persons age 14
and over.
Prosthodontic Not Covered
Prophylaxis
Diagnostic Imaging (X-rays/Films)
Bitewings Type 2 - Basic 1 per D0270 D0272 The maximum amount considered for x-ray
benefit D0273 D0274 radiographic images taken on one day will be
period D0277 equivalent to an allowance of a D0210.
Fullmouth Type 3 - Major 1 in 5 years D0210 D0330
Periapicals Type 3 - Major 1 per D0220 D0230
benefit
period
Current Dental Terminology copyrighted American Dental Association.
BENEFIT PERIOD: PLEASE NOTE: The service categories and plan
Insured Benefit Year: The plan benefit period limitations shown represent an overview of your plan
begins on the plan member's individual effective benefits. The summary represents the majority of
date. services within each category and coverage may vary
depending on procedure code and whether the service
is covered. Pretreatments are strongly suggested.
Service Benefit Type Frequency Additional Information
Restorative
Sealant Type 2 - Basic 1 in 3 years To age 16. Benefits are considered on permanent
molars and bicuspids only. Coverage is allowed on the
occlusal surface only.
Amalgam Type 2 - Basic 1 in 2 years
Composite Type 2 - Basic 1 in 2 years Porcelain and resin benefits are considered for anterior
teeth only. Coverage is limited to necessary placement
resulting from decay or replacement due to existing
unserviceable restorations.
Crowns Type 3 - Major 1 in 60 Porcelain and resin benefits are considered for anterior
months teeth only. Procedures that contain titanium, high
noble metal, or noble metal will be considered at the
corresponding base metal allowance. Benefits will not
be considered if procedure D2390, D2928, D2929,
D2930, D2931, D2932, D2933 or D2934 has been
performed within 12 months.
Onlays Type 3 - Major 1 in 5 years Porcelain and resin benefits are considered for anterior
teeth only. Benefits will not be considered if
procedure D2390, D2928, D2929, D2930, D2931,
D2932, D2933 or D2934 has been performed within 12
months.
Inlays Type 3 - Major 1 in 5 years Porcelain and resin benefits are considered for anterior
teeth only.
Veneers Type 3 - Major 1 in 5 years Benefits are considered on anterior teeth only.
Crown Buildups Type 3 - Major Contact us
Post and Core Type 3 - Major Contact us
Endodontics
Root Canals Type 3 - Major No Benefits are considered on permanent teeth only.
Frequency Allowances include intraoperative radiographic images
and cultures but exclude final restoration.
Root Canal Type 3 - Major 1 in 3 years Benefits are considered on permanent teeth only.
Retreatment Coverage is limited to service dates more than 12
months after root canal therapy. Allowances include
intraoperative radiographic images and cultures but
exclude final restoration.
Surgical Type 3 - Major No
Endodontics / Frequency
Apicoectomy
Therapeutic Type 3 - Major No
Pulpotomy Frequency
Periodontics
Antimicrobial Not Covered
Agent
Root Planing and Type 3 - Major 1 in 2 years
Scaling
Fullmouth Not Covered
Debridement
Surgical Type 3 - Major Various Pretreatment is strongly suggested.
Periodontics frequencies
apply
Gingivectomy Type 3 - Major 1 in 3 years
Oral Surgery
Non-Surgical Type 3 - Major No
Extractions Frequency
Surgical Type 3 - Major No
Extractions Frequency
Other Oral Type 3 - Major No
Surgery Frequency
General Anesthesia
General Type 3 - Major No Coverage is available when done in conjunction with
Anesthesia and/or Frequency any covered dental procedure. A maximum of four
IV Sedation (D9222, D9223, D9239 or D9243) will be considered.
Nitrous Oxide Not Covered
Removable Prosthodontics (Dentures)
Removable Type 3 - Major 1 in 5 years Allowances include adjustments within 6 months of
Prosthodontics placement date.
(Dentures)
Denture Relines Type 3 - Major 1 in 2 years Coverage is limited to service dates more than 12
months after placement date.
Denture Rebases Type 3 - Major 1 in 2 years Coverage is limited to service dates more than 12
months after placement date.
Denture Type 3 - Major No Coverage is limited to dates of service more than 12
Adjustments Frequency months after placement date.
Denture Repairs Type 3 - Major No Coverage is limited to service dates more than 12
Frequency months after placement date.
Implants are not a covered benefit
Implants Not Covered
Implant Not Covered
Supported Crown
Implant Not Covered
Supported
Retainer
Implant Services Not Covered
List
Fixed Prosthodontics (Bridges)
Bridges Type 3 - Major 1 in 5 years Porcelain and resin benefits are considered for anterior
teeth only. Procedures that contain titanium, high
noble metal, or noble metal will be considered at the
corresponding base metal allowance. Benefits will not
be considered if procedure D2390, D2928, D2929,
D2930, D2931, D2932, D2933 or D2934 has been
performed within 12 months.
Tests and Examinations
Prediagnostic Not Covered
Cancer Screen
Test
Occlusal Guard
Occlusal Guard Type 3 - Major 1 in 5 years Benefits will not be available if performed for athletic
purposes.
*Charting may be required for periodontal procedures.
*Radiographic images (x-rays) may be required for surgical procedures such as: crowns, onlays, build-ups and post and cores, if
applicable.
