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Premier PPO HIGH PLAN
Premier PPO LOW PLAN
ADVANTAGE PPO PLAN
ADVANTAGE COPAY PLAN
Premier Network
Out of Network
Premier Network
Out of Network
Advantage Plus Network
Out of Network
Advantage Network
Out of Network
Services
Preventive
100%
100% up to MAC*
100%
80% up to MAC*
100%
100% up to MAC*
100%
See CoPay Schedule
Basic
80%
80% up to MAC*
60%
50% up to MAC*
50%
50% up to MAC*
See CoPay Schedule
Major
50%
50% up to MAC*
40%
30% up to MAC*
25%
25% up to MAC*
Orthodontics (Up to age 19**)(Medically Necessary)
50%
50%
50%
50%
50%
50%
50%
50%
Orthodontics (Up to age 19**)(Non-Medically Necessary)
50%
50%
Discount Only
Not Covered
Discount Only
Not Covered
Discount Only
Not Covered
Waiting Periods
Preventive
None
None
None
None
Basic
6 Month Waiting Period
6 Month Waiting Period
6 Month Waiting Period
6 Month Waiting Period
Major
15 Month Waiting Period
18 Month Waiting Period
12 Month Waiting Period
12 Month Waiting Period
Orthodontics(Medically Necessary / Non-Medically Necessary)
None / 24 Month Waiting Period
None / Not Applicable
None / Not Applicable
None / Not Applicable
Deductible (applies to Preventive, Basic and Major)
Individual
$25
$100
$100
$50
Family Max
$75
$300
$300
$150
Maximums
Major Annual Max (age 19 and older)
$750
$500
$500
No Maximum
Annual Max per Person (age 19 and older)
$1,000
$1,000
$1,000
No Maximum
Orthodontic Lifetime Max(Medically Necessary / Non-Medically Necessary)
No Maximum / $1,000
No Maximum / Not Applicable
No Maximum / Not Applicable
No Maximum / Not Applicable
Pediatric EHB Annual Max
No Maximum
No Maximum
No Maximum
No Maximum
Pediatric Individual EHB Out-of-Pocket Max(up to age 19**)
$425
$425
$425
$425
Pediatric Family EHB Out-of-Pocket Max(up to age 19**)
$850
$850
$850
$850
View Plan Details
See Plan Details
See Plan Details
See Plan Details
See Plan Details
Benefits illustrated are in summary only. Refer to your Dental Insurance Policy for a complete description of benefits, limitations and exclusions.
*All Services are subject to EMI Health Maximum Allowable Charge (MAC). When using a Non-participating Provider, the insured is responsible for all fees in excess of the Maximum Allowable Charge (MAC). Underwritten by Companion Life Insurance Company.
**Through the last day of the month in which the Insured turns 19 years of age
The Companion Life EMI Health dental plans have been reviewed and approved by the Illinois Insurance Department. They meet all Federal regulations, fulfilling the requirements of the Affordable Care Act for individuals.
Transparency in Coverage and General Policy Provisions (责任编辑：)
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