WREA Dental/Eye Care Program

There are three dental plans available:

Economy Plan (Dental/Vision Plan)
Value Plan (Dental/Vision Plan
100/80/50 Plan (Dental Only)

Sample Schedule of Benefits of how much the insurance will pay There are over 250 covered procedures, below is only a sample.	Economy	Value
Deductible—$50 Calendar Year-Per Person Deductible for Basic and Major Services ONLY!
Elimination Period—12 Month Waiting Period on Major Procedures
Plan Maximum Per Calendar Year-Per Person - $750 Calendar Year-Per per Person Maximum of which no more than $350 of that per calendar year will be paid on Major Procedures
Preventive * - NO DEDUCTIBLE
Two cleanings per calendar year - Adult	$28 each	$39 each
Two evaluations per calendar year	$11 each	$16 each
Fluoride for Children (Under age 19)	$11	$15
Basic
Entire denture x-ray series consisting of at least 14 films, including bitewings if necessary	$34	$47
Bitewing x-rays (two films) twice in a calendar year	$12	$17
Amalgam restoration (silver fillings)—one surface, permanent	$29	$41
Extraction—single tooth	$34	$47
Surgical removal of tooth (completely bony)	$70	$98
Anesthesia, general, when administered by the dentist in the dentist's office	$98	$137
Major
Maxillary partial denture—resin base	$210	$293
Denture repair-Repair Broken Base	$25	$35
Endodontics—root canal, anterior	$112	$156
Periodontal scaling and root planning, limited (per quadrant).	$36	$51
Crown—full cast noble metal	$157	$218
Crown repair	$42	$59
Pontics—porcelain fused to noble metal	$157	$218
Monthly Premiums
Single Only	$15.89	$23.22
Insured & One (Spouse or Child)	$31.69	$46.44
Insured & 2 or More	$47.65	$69.65

*Please refer to your certificate of insurance for complete details on all benefits, frequencies and plan limitations or view the limitations below

Outline of Benefits Benefits may be subject to usual & customary charges in your area	Coverage	Sample Procedures *Please refer to your certificate for complete details on all benefits, frequencies, and plan limitations. A certificate will be mailed after your enrollment form has been processed.
Preventive *No Deductible	100%	ü Two evaluation per calendar year ü Two cleanings per calendar year ü Fluoride treatment for children under age 19 ü Space Maintainers
Basic	80%	ü Radiograph x-rays ü Bitewings allowed twice in a calendar year ü Limited exams for focused problem ü Restorative amalgams (Fillings) ü Oral surgery – simple and complex extractions ü Anesthesia ü Denture Repair ü Sealants for children under age 17
Major	50%	ü Crown Repair ü Endodontics (Root Canals) ü Endodontics (Apicoectomy) ü Periodontics (Gum Disease) ü Restorative—Crowns ü Prosthodontics—Fixed Pontics or Abutments, Removable Dentures, Partials
Monthly Premiums
Single Only	$47.69
Insured & One (Spouse or Child)	$92.96
Insured & 2 or More	$127.61

*Please refer to your certificate of insurance for complete details on all benefits, frequencies and plan limitations or view the limitations below

Ameritas Group Dental and EyeCare - Dental Limitations and Exclusions for all three dental plans:

Covered Expenses will not include and benefits will not be payable for expenses incurred:

for Type 3 Procedures in the first 12 months the person is covered under this contract
in the first 12 months that a person is insured if the person is a Late Entrant; except for evaluations, prophylaxis (cleanings), and fluoride application.
for initial placement of any prosthetic crown, appliance, or fixed partial denture unless such placement is needed because of the extraction of one or more teeth while the insured person is covered under this contract. But the extraction of a third molar (wisdom tooth) will not qualify under the above. Any such prosthetic crown, appliance, or fixed partial denture must include the replacement of the extracted tooth or teeth
for appliances, restorations, or procedures to: a. alter vertical dimension; b. restore or maintain occlusion; or c. splint or replace tooth structure lost as a result of abrasion or attrition
for any procedure begun after the insured person's insurance under this contract terminates or for any prosthetic dental appliances installed or delivered more than 90 days after the Insured's insurance under this contract terminates
to replace lost or stolen appliances
for any treatment which is for cosmetic purposes
for any procedure not shown in the Table of Dental Procedures. (There may be additional frequencies and limitations that apply, please see the Table of Dental Procedures for details.)
for orthodontic treatment under this benefit provision. (If orthodontic expense benefits have been included in this policy, please refer to the Schedule of Benefits and Orthodontic Expense Benefits provision found on 9260)
for which the Insured person is entitled to benefits under any workmen’s compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit
for charges which the Insured person is not liable or which would not have been made had no insurance been in force
for services that are not required for necessary care and treatment or are not within the generally accepted parameters of care
because of war or any act of war, declared or not

Vision Service Plan - Eye Care Limitations and Exclusions:

Covered Expenses will not include and benefits will not be payable for expenses incurred for:

vision examinations more than the frequency as indicated on the plan summary page
lenses more than the frequency as indicated on the plan summary page
frames more than the frequency as indicated on the plan summary page
contact lenses more than once in any twelve month period. When chosen, contact lenses shall be in lieu of any other lens or frame benefit during the twelve month period. When lenses and frames are chosen, expenses for contact lenses are not Covered Expenses during the twelve month period
examinations performed or frames or lenses ordered before the member was covered under the eye care expense benefits.
subject to extension of benefits, any examination performed or frame or lens ordered after the member's coverage under the eye care expense benefits ceases
sub-normal eye care aids; orthoptic or eye care training or any associated testing.
non-prescription lenses.
replacement or repair of lost or broken lenses or frames except at normal intervals.
any eye examination or corrective eyewear required by an employer as a condition of employment.
medical or surgical treatment of the eyes.
any service or supply not shown on the Schedule of Eye Care Procedures.
coated lenses; oversize lenses (exceeding 71 mm); photo-gray lenses; polished edges; UV-400 coating and facets, and thints other than solid.