Affordable Dental Benefits for You and Your Family

Why choose AlwaysCare ONE plus ?
• Affordable dental coverage for as low as $19.24 per month • You choose the plan that is right for you! Three dental plan options available to best meet your family’s needs

Plus

Hearing Savings Plan at no additional cost to you! Material discounts between 30-60% on major name brand hearing instruments and accessories. Battery program with discounts up to 40% off retail pricing. D E N TA L P L A N - O U T L I N E O F BE N E F I T S Freedom of Choice. Choose any dental provider or visit one of over 144,000 participating provider access points in our network and pay even less. Visit www.AlwaysCareBenefits.com for a listing of participating providers. Each plan reimburses for covered procedures up to the scheduled amount in your policy. See page 2 for examples. Benefit Year Maximum. $1,000 per person per benefit year (Applies to all services) Deductible. $50 Annual. Maximum 3 per family (Does not apply to preventive services) Preventive Services. • Routine exams (2 per 12 months) • Prophylaxis (Simple Cleaning) (2 per 12 months) • Full mouth x-ray (1 per 24 months) • Space maintainers to age 16 (1 per 24 months) • Fluoride to age 16 (1 per 12 months) • Bitewing x-rays (max 4 films per 12 months) • Sealants to age 16 (permanent molars, 1 per 36 months) • Adjunctive pre-diagnostic oral cancer screening (max 1 per 12 months for age 40+)

Other Services. 12 month waiting period applies. • Fillings (12 month waiting period does not apply to fillings) • Simple extractions • Oral surgery (surgical extractions & impactions) • Anesthesia
(subject to review, covered with complex oral surgery)

• Emergency pain (1 per 12 months) • Non-Surgical Periodontics • Crowns, Bridges, and Dentures • Surgical Periodontics (gum surgery) • Inlays and Onlays • Endodontics (root canals) • Repairs: Crown, Denture, and Bridge

DID YOU KNOW? Regular dental care is a vital part of your overall wellness plan. According to the American Dental Association, over 120 mental and physical diseases can be detected through the mouth. In fact, periodontitis (the advanced form of gum disease that can cause tooth loss) is associated with cardiovascular disease, stroke and bacterial pneumonia and is best detected with routine dental visits.

How the DENTAL plan works: Each plan pays a flat dollar amount per dental procedure based on the fee schedule in your policy. Visit one of our innetwork providers for additional savings. We will pay the lesser of the provider’s actual charge or the amount listed on the Schedule of Covered Dental Procedures, subject to policy year deductible, annual maximum, and limitations and exclusions. The following is a partial listing of the 300+ insured covered dental procedures and schedule amounts. Choose the right plan for you and your family – Value, Standard or Preferred!
S A M P L I NG OF C OV E RE D DE N TAL P ROCEDURES SCH EDULE A MOUN T

PROCEDURE CODE
Oral Evaluations } D0120 D0150 D1110 D1120 Radiographs } D0210 D0272 D0330 Sealants } D1351 Space Maintainers } D1510 Fillings } D2140 D2150 D2331 Palliative D9110 Oral Surgery * } D7140 D7230 Endodontics * } D3310 D3330 Periodontics * D4260 D4341 Single Tooth Restorations* } D2750 D2950 D2952 Prosthodontics * D5110 D5213 D6210 D6721
* Waiting

DESCRIPTION
Periodic Oral Evaluation

VALUE PLAN
$19 $31 $36 $26 $53 $17 $43 $21 $132 $39 $48 $55 $16 $44 $63 $114 $171 $170 $38 $167 $39 $59 $189 $214 $158 $148

STANDARD PLAN
$27 $44 $52 $37 $75 $24 $61 $30 $187 $56 $68 $79 $23 $62 $89 $162 $242 $241 $54 $237 $56 $83 $268 $303 $223 $209

PREFERRED PLAN
$35 $57 $67 $48 $98 $31 $79 $39 $242 $72 $88 $102 $29 $81 $116 $209 $313 $312 $70 $306 $72 $108 $347 $393 $289 $271

Comprehensive Oral Evaluation Prophylaxis (Simple Cleaning) } Prophylaxis - Adult Prophylaxis - Child Intraoral - Complete Series (Including Bitewings) Bitewings - Two Films Panoramic Film Sealant - Per Tooth Space Maintainer - Fixed - Unilateral Amalgam - One Surface, Primary or Permanent Amalgam - Two Surfaces, Primary or Permanent Resin - Two Surfaces, Anterior (Emergency Treatment)* } Palliative Treatment of Dental Pain - Minor Procedure Extraction - Erupted or Exposed Root Removal of Impacted Tooth - Partially Bony Root Canal, Anterior Root Canal, Molar } Osseous Surgery - Per Quadrant Periodontal Scaling and Root Planing - Per Quadrant Crown - Porcelain Fused to High Noble Metal Core Build-up, Including Any Pins Post and Core in Addition to Crown, Indirectly Fabricated } Complete Denture - Maxillary Maxillary Partial Denture - Cast Metal Pontic - Cast High Noble Metal Crown - Resin with Predominantly Base Metal period applies.

MORE ABOUT YOUR COVERAGE When does your coverage start? Your coverage start date is determined by the date the application is received*. • If your application is received on or before the 25th of the month, coverage will start on the 1st of the next month. For example, if we receive it on November 15th coverage will start December 1st. If your application is received after the 25th of the month, coverage will start on the 1st of the following month. For example, if we receive it on November 26th coverage will start January 1st.

•

The first premium payment will be processed immediately based on the mode of payment you have selected. Future premium payments will be processed automatically on or about the 2nd of the month for which premium is due.
*If the initial premium is not successfully processed, you will be notified and coverage will not be put in force.

How much does it cost*?
M O N T H LY D E N TA L R AT E S

For Adults (Ages 19 to 64)
Individual Individual + Spouse Individual + Children Individual + Family

VALUE PLAN
$19.24 $38.48 $40.85 $64.10

STANDARD PLAN
$27.25 $54.51 $57.88 $90.81

PREFERRED PLAN
$35.27 $70.54 $74.90 $117.52

M O N T H LY D E N TA L R AT E S

For Seniors (Ages 65 +)
Individual Individual + Spouse Individual + Children Individual + Family

VALUE PLAN
$24.18 $48.35 $45.79 $73.98

STANDARD PLAN
$34.25 $68.50 $64.87 $104.80

PREFERRED PLAN
$44.32 $88.65 $83.95 $135.62

* Your rate is determined by your age when the policy is issued.

Enroll today at www.AlwaysCareOnePlus.com!
P.O. Box 98100 • Baton Rouge, Louisiana 70898-9100 1-888-729-5433 • www.AlwaysCareBenefits.com
Policy Form Series IDN-2009 Underwritten by Starmount Life Insurance Company and administered by AlwaysCare Benefits, Inc. (a Starmount Life Insurance company). Please Note: A full listing of covered procedures will be provided with your policy. This form is not a contract of insurance. This is a brief description of the plan and should be used only as a guide. It does not contain complete plan details. Terms and conditions, including a complete list of benefits, limitations and exclusions, are defined in the policy issued following enrollment in the plan. If questions arise concerning coverage, the policy will govern. Not available in all states. Rates and benefits may vary by state. Call 1-888-729-5433, Ext. 2013 for state availability. IND DENTAL ONLY FLY 0611