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MULTIFLEX DENTAL COVERAGE INFORMATION

Introducing Multiflex, a comprehensive dental insurance plan created to offer you and your qualified family members the protection and flexibility you need to maintain your winning smile.

When you enroll with Multiflex, you receive affordable coverage for basic, preventive, and major dental services. Since you will be automatically accepted, your coverage begins the month after you application is received. What's more, this plan is fee of networks, so you have the power to keep your current dentist or choose a new one.

After you review the list of benefits Multiflex offers you and your family, complete and mail the enclosed enrollment form today. Just as soon as you receive your policy, you may begin enjoying the available benefits of the Multiflex Dental Insurance Plan.

COVERAGE ELIGIBILITY

All members and their spouse, regardless of age, and their children under 19 (23 if a full-time student) can enroll in this comprehensive dental coverage. Coverage is available for children only. Six Month waiting period for Basic Services, 18 Month waiting period for Major Services applies.

ELIGIBLE EXPENSES

For the plan to pay for covered expenses, a covered person must incur all eligible expenses while the policy is in force. Eligible expenses are dental services performed by:
  1. a licensed dentist acting within the scope of his license,
  2. a licensed physician performing dental services within the scope of his license, or
  3. a licensed dental hygienist acting under the supervision and direction of a dentist.

TERMINATION OF INSURANCE

The insurance of the policy holder may be terminated only: 

MULTIFLEX DENTAL PLAN COVERAGE INFORMATION
 

Benefits will be paid for reasonable and customary fees as defined by the plan policy. This plan has a maximum calendar year benefit for all services of $1,000, $1,500 or $2,000 per person depending on plan chosen. Six Month waiting period for Basic Services, 18 Month waiting period for Major Services applies.

SCHEDULE  OF  DENTAL  BENEFITS
 Group Master Policy Form Number: GH-1112-38200

 

Waiting Period

Multiflex Covers

Multiflex Pays

Your Co-Payment

Preventive Dental Services
Benefits Begin Immediately

•

Two Routine Exams of Mouth and Teeth per calendar year

•

Two Cleanings, Sealings, and Polishings per calendar year

•

Space Maintainers

 

Under age 65
 100% of all covered charges

•

0% Coinsurance

•

$50 per member Calendar year deductible*

 

Over age 65
 80% of all covered charges

•

20% Coinsurance

•

$75 per member Calendar year deductible*

 

Basic Services
Benefits Begin After Six Months

•

Extraction of Teeth

•

X-rays

•

Pin Retention of Fillings

•

Fillings

•

Antibiotic Injections

 

Under age 65
 80% of all covered basic services

•

20% Coinsurance

•

$50 per member Calendar year deductible*

 

Over age 65
 80% of all covered basic services

•

20% Coinsurance

•

$75 per member Calendar year deductible*

 

Major Services
Benefits Begin After 18 Months

•

Oral Surgery

•

Endodontic Treatment of Disease

•

Periodontic Services

•

Crown Build Up

•

Recementing

•

Denture or Bridge Repair

•

General Anesthesia and Analgesic

•

Restoration Services

•

Prosthetic Services

 

Under age 65
 50% of all covered major services

•

50% Coinsurance

•

$50 per member Calendar year deductible*

 

Over age 65
 50% of all covered major services

•

50% Coinsurance

•

$75 per member Calendar year deductible*

 

The plan will pay the usual and customary charge for dental procedures and services after any required deductible amount as shown below.

Effective Date:
  

Your order must be received by the 5th day of the month for coverage to start on the 1st of the same month. Otherwise, the coverage will not start until the 1st day of next month. You and Your Dependents are covered on the later of: the date We accept Your enrollment and determine an effective date; or the date You first acquire a Dependent, if the date is after Your coverage begins.

Class A:  Preventive Services Include:

  1. Two routine (including any initial exam) examinations of mouth and teeth per calendar year;
  2. Two prophylaxis (cleaning and polishing teeth) per calendar year;
  3. One topical fluoride per calendar year to age 16;
  4. Space maintainers to preserve space between teeth for premature loss of a primary baby tooth.  This does not include use for orthodontic treatment.

Class B:  Basic Services Include:

  1. Simple extraction of teeth;
  2. Bitewing x-rays, 2 per calendar year;
  3. One diagnostic x-ray, full or panoramic in any 3 year period, and;
  4. Pin retention of fillings;
  5. Fillings of amalgam, silicate, acrylic, synthetic porcelain and composite filling materials (restorations of mesioilingual, distolingual, mesiobuccal and distobuccal surfaces considered single surface restorations);
  6. Antibiotic injections administered by Dentist.

Class C:  Major Services Include:

  1. Oral surgery, including post-operative care for:
    1. removal of teeth, including impacted teeth;
    2. extraction of tooth root;
    3. alveolectomy, alveoplasty and frenectomy;
    4. excision of periocoronal gingiva, exostosis or hyperplastic tissue and excision of oral tissue for biopsy;
    5. reimplantation or transplantation of a natural tooth; and
    6. excision of a tumor or cyst and incision and drainage of an abscess or cyst.
  2. Endodontic treatment of disease of the tooth, pulp, root and related tissue as follows:
    1. root canal therapy (not covered if pulp chamber was opened before covered);
    2. pulpotomy;
    3. apicoectomy; and;
    4. retrograde fillings.
  3. Periodontic services, limited to:
    1. two prophylaxis following surgery per calendar year;
    2. root scaling and planing, once per quadrant of mouth in any 6 month period;
    3. occlusal adjustment, performed with covered surgery;
    4. gingivectomy, gingival curettage and mucogingival;
    5. osseous surgery including flap entry and closure;
    6. pedical or free soft tissue grafts; and
    7. one appliance (night guards) in 5 year period.
  4. One study models in 3 year period;
  5. Crown buildup for non-vital teeth;
  6. Recementing inlays, onlays and crowns;
  7. Recementing bridges;
  8. One repair of dentures or bridges in any 2 year period, limited to 20% of cost of replacement;
  9. General anesthesia and analgesic, including intravenous sedation for oral surgery;
  10. Restoration services, limited to:
    1. gold or porcelain inlays, onlay, and crowns for tooth with extensive caries or fracture that is unable to be restored with an amalgam, silicate, acrylic, synthetic porcelain or composite filling material;
    2. replacement of existing inlay, onlay or crown after 5 years of the restoration initially placed or last replaced.  This limitation will not apply if replacement is necessary due to the extraction of functioning natural teeth while covered;
    3. stainless steel crowns;
    4. post and core.
  11. Prosthetic services, limited to:
    1. initial placement of dentures or fixed bridgework (including acid etch metal bridges), when denture or bridgework includes replacement of a natural tooth extracted or lost while covered under the Policy.  This limitation ends after covered under the Policy for 36 months;
    2. replacement of dentures or fixed bridgework that cannot be repaired after 5 years from the date of placed or last replaced;
    3. addition of teeth to existing partial denture, only if to replace natural teeth extracted or lost while covered under the Policy.  This limitation will not apply after covered under the Policy for 36 months;
    4. relining or rebasting of existing removable dentures, only after one year from date the denture was placed and only once in any 2 year period.

Additional Important Information

Eligible Expenses:

We will pay for Eligible Expenses You incur for Yourself or on behalf of Your insured Dependent. Expenses must be incurred while the Policy is in force and the person is covered by the Policy. The description of Eligible Expenses is shown in the Coverage Schedule. To be an Eligible Expense, the dental service or procedure must be performed by a Dentist, a Physician or a Dental Hygienist.

Expenses Incurred:

An Eligible Expense is considered incurred on the following dates: For full and partial dentures - the date the final impression is taken; for fixed bridges, crowns, inlays and onlays - the date the teeth are first prepared; for root canal therapy - on the date the pulp chamber is opened; for periodontal surgery - on the date surgery is performed; for all other services - the date the service is performed.

Deductible Amount:

The calendar year Deductible, if any, is shown in the Coverage Schedule. The Deductible is an amount of charges You must incur for Yourself or on behalf of Your insured Dependent before We start paying benefits.

Maximum Calendar Year Limit:

The maximum limit payable for all Eligible Expenses in any calendar year is shown in the Coverage Schedule. The Maximum Calendar Year Limit, if any, will apply to each person covered under the Policy.

Pretreatment Review:

If the Course of Treatment will exceed the amount shown in the Coverage Schedule, We will request prior review. We must be given the Dentist’s treatment plan consisting of a description of the planned treatment with estimated charges and diagnostic x-rays. We will determine Eligible Expenses and state how much We will pay for the treatment. Our determination may suggest an alternate less expensive Course of Treatment if it will produce professionally satisfactory results. If You do not request a pretreatment review We will pay for the least expensive method of treatment regardless of the method actually used.

Coordination of Benefits:

If any person under the Policy (referred to as "this Plan") is also covered under one or more other plans, the benefit under this Plan will be coordinated with benefits payable under all other plans.

Alternate Benefit:

If: 1) We determine that a less expensive alternate procedure, service or Course of Treatment can be performed in place of the proposed treatment to correct a dental condition; and 2) the alternative treatment will produce a professionally satisfactory result; then the maximum We will allow will be the charge for the less expensive treatment.

Eligibility:

Individuals, 18 years of age or older, plus their eligible dependents (spouse and unmarried children from birth to age 19; extended to age 23 if child is a full-time student). This is subject to State requirements.

Termination of Coverage:

Coverage terminates on the earliest of the following dates: (a) the last day of the month in which You cease to be eligible for coverage; (b) the last day of the month in which Your Dependent is no longer a dependent as defined; (c) subject to the Grace Period, the last day of the month for which a premium has been paid by you or on your behalf; (d) or the date the Master Policy ends.

Reasonable and Customary:

Reasonable and Customary means the usual, customary and regular charges for the area where such expenses are incurred.

Dental Expenses NOT Covered:

  1. For overdentures and associated procedures for charges in excess of those considered reasonable and customary;
  2. For cosmetic procedures;
  3. For the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function;
  4. For implants and for replacement of lost or stolen appliances, replacement of retainers, athletic mouthguards, precision or semi-precision attachments, denture duplication;
  5. For oral hygiene instructions and for plaque control, completion of a claim form, acid etch, broken appointments, prescription or take-home fluoride, or diagnostic photographs;
  6. For services not completed by the end of the month in which coverage ends unless continuation of coverage has been requested and accepted by Us;
  7. For procedures that are begun, but not completed;
  8. For services and treatment provided without charge or for which there would be no charge in the absence of insurance;
  9. For services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries;
  10. For a condition covered under any Worker's Compensation Act or similar law; that are applied toward satisfaction of a Deductible, if any; that are generally considered by the dental profession as experimental or investigational;
  11. For the treatment of cleft palate and anodontia;
  12. For services or supplies payable under any medical expense plan;
  13. For orthodontia, unless included within Coverage Schedule;
  14. Prior to the date the Insured is covered under the Policy;
  15. For the diagnosis or treatment of TMJ;
  16. For hospital services;
  17. For any unmarried child age 19 years of age and over unless he is dependent upon You for support, while a full-time student. A full-time student is one who is enrolled for 12 semester hours for credit in an accredited junior college, college or university. Any exception for a full-time student will end at age 23;
  18. During any waiting period We require, when You voluntarily end Your insurance and re-enroll at a later date, Your waiting period is 2 years and begins on the date Your coverage first ended.

IMPORTANT FRAUD NOTICES

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

STATE SPECIFIC NOTICES:

Pennsylvania - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material hereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.


* You only have to pay one calendar year deductible across all classes of benefits. Under 65: $50 Member deductible, $100 Member plus one deductible, $150 Family deductible. Preventive services covered at 100%. Over 65: $75 Member deductible, $150 Member plus one, $225 Family deductible. Preventive services covered at 80%.

*Coverage for this product may not be available in some states. This brochure provides a brief description of some important features of the Multiflex Plan. It is not the insurance contract, nor does it represent the insurance contract. A full explanation of benefits, exceptions and limitations is contained in the Certificate of Insurance.

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