What is the Premier PPO High Plan?
EMI Health's Premier PPO High 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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| Plan Summary | Premier Network | Out-of-Network |
| Services | ||
|
Preventive
Oral Exams, Cleanings, Sealants, X-rays, Fluoride
|
100% | 100% up to MAC* |
|
Basic
Fillings, Space Maintainers, Oral Surgery
|
80% | 80% up to MAC* |
|
Major
Crowns, Bridges, Prosthodontics, Endodontics, Periodontics
|
50% | 50% up to MAC* |
|
Orthodontics (up to age 19**)
(Medically Necessary / Non-Medically Necessary)
|
50% / 50% | 50% / 50% |
| Waiting Periods | ||
| Preventive | None | |
| Basic (age 19 and older) | 6 Month Waiting Period | |
| Major (age 19 and older) | 15 Month Waiting Period | |
|
Orthodontics
(Medically Necessary / Non-Medically Necessary)
|
None / 24 Month Waiting Period | |
| Deductible (applies to Preventive, Basic and Major) | ||
| Individual | $25 | |
| Family Max | $75 | |
| Maximums | ||
| Major Annual Max (age 19 and older) | $750 | |
| Annual Max per Person (age 19 and older) | $1,500 | $1,000 |
|
Orthodontic Lifetime Max
(Medically Necessary / Non-Medically Necessary)
|
No Maximum / $1,000 | |
| 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