What is the Choice PPO Low Plan?
EMI Health's Choice PPO Low Plan is a rich dental benefit plan. This plan is a coinsurance plan, which means we share your costs for covered dental services and procedures. Once you've met your deductible, we'll pay a percentage of your bill.
You can choose to visit dentists in different networks based on your needs. If you use the Advantage network, you'll see more savings. If your dentist isn't in the Advantage network, see if they are in the larger Premier network here: Provider Search.
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| Plan Summary | Advantage Network | Premier Network | Out-of-Network |
| Services | |||
|
Preventive
Oral Exams, Cleanings, Sealants, X-rays, Fluoride
|
100% | 100% | 80% up to MAC* |
|
Basic
Fillings, Space Maintainers, Oral Surgery
|
60% | 60% | 50% up to MAC* |
|
Major
Crowns, Bridges, Prosthodontics, Endodontics, Periodontics
|
50% | 40% | 30% up to MAC* |
|
Orthodontics (up to age 19**)
(Medically Necessary / Non-Medically Necessary)
|
50% / Discount Only (Up to 25%) | 50% / Discount Only (Up to 25%) | 50% / Not Covered |
| Waiting Periods | |||
| Preventive | None | ||
| Basic | None | ||
| Major (age 19 and older) | 18 Month Waiting Period | ||
|
Orthodontics
(Medically Necessary / Non-Medically Necessary)
|
None / Not Applicable | ||
| Deductible (applies to Preventive, Basic and Major) | |||
| Individual | $100 | ||
| Family Max | $300 | ||
| Maximums | |||
| Major Annual Max per person (age 19 and older) | $500 | ||
| Annual Max per person (age 19 and older) | $1,500 | $1,000 | |
|
Orthodontic Lifetime Max
(Medically Necessary / Non-Medically Necessary)
|
No Maximum / Not Applicable | ||
| Pediatric EHB Annual Max | No Maximum | ||
| Pedriatric Individual EHB Out-of-Pocket Max | $375 | ||
| Pediatric Family EHB Out-of-Pocket Max | $750 | ||
Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.
*All Services are subject to 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 Educators Health Plans Life, Accident, and Health, Inc.
**Through the last day of the month in which the Insured turns 19 years of age