What is the Premier PPO Dental Insurance Low Plan?
The Companion EMI Health Premier PPO Dental Insurance Low 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.
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Language Assistance
If you, or someone you’re helping, has questions about the EMI Health Policy, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 800-662-5851 (TTY: 1-888-236-4823).
| Plan Summary | Premier Network | Out-of-Network |
| Services | ||
|
Preventive
Oral Exams, Cleanings, Sealants, X-rays, Fluoride
|
100% | 80% up to MAC* |
|
Basic
Fillings, Space Maintainers, Oral Surgery
|
60% | 50% up to MAC* |
|
Major
Crowns, Bridges, Prosthodontics, Endodontics, Periodontics
|
40% | 30% up to MAC* |
|
Orthodontics (Up to age 19*)
(Medically Necessary / Non-Medically Necessary)
|
50% / Discount Only | 50% / Not Covered |
| Waiting Periods | ||
| Preventive | None | |
| Basic (age 19 and older) | 6 Month Waiting Period | |
| 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 (age 19 and older) | $500 | |
| Annual Max per Person (age 19 and older) | $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 | $425 | |
| Pediatric Family EHB Out-of-Pocket Max | $850 | |
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 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