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VoluntaryMart Dental
Benefit Summary

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Benefit Summary

Level 1

Level 2

Level 3

Dental Wellness – exams, radiographs, cleanings, fluoride, sealants, space maintainers

$25/visit
2 visits/policy year

$50/visit
2 visits/policy year

$75/visit
2 visits/policy year

Basic Dental Services

Benefits are paid at 50% of the scheduled amount for the first policy year*, then 100% of scheduled amount thereafter up to the annual maximum. Scheduled amounts are based on procedure, up to:

• Anesthesia/Pain

$25 per each 15 minutes

$50 per each 15 minutes

$75 per each 15 minutes

• Fillings – scheduled amounts:

$100/filling

$160/filling

$220/filling

• Simple Extractions

$20/extraction

$40/extraction

$60/extraction

• Prosthodontic Adjustments and Repairs

$60/procedure

$120/procedure

$180/procedure

Major Dental Services

Benefits are paid at 20% of the scheduled amount for the first policy year*; Benefits are paid at 50% of the scheduled amount for the second policy year; then 100% of scheduled amount thereafter up to the annual maximum. Regional scheduled amounts listed below are based on a procedure.

Region 1 / 2 / 3 / 4 / 5: 

• Inlays/Onlays

$120/$145/$175/$210/$250

$190/$230/$275/$330/$395

$260/$310/$375/$450/$540

• Crowns

$105/$125/$150/$180/$215

$210/$250/$300/$360/$430

$315/$375/$450/$540/$650

• Endodontics

$140/$165/$200/$240/$290

$210/$250/$300/$360/$430

$280/$335/$400/$480/$575

• Periodontics

$125/$150/$180/$215/$260

$165/$200/$240/$290/$345

$210/$250/$300/$360/$430

• Prosthodontics

$120/$145/$175/$210/$250

$210/$250/$300/$360/$430

$280/$335/$400/$480/$575

• Oral Surgery

$345/$415/$500/$500/$500

$520/$625/$750/$750/$750

$695/$835/$1000/$1000/$1000

*Combined Basic & Major Services Annual Maximum Options

$500, $750, or $1000per calendar year

$750, $1000, or $1250per calendar year

$1000, $1250, or $1500per calendar year

Temporomandibular Joint Services

Benefits are payable after the policy has been in force two years*, up to a $500 lifetime maximum. Regional scheduled amounts are based on procedure, Region 1 /2/3/4/5, up to:

$345/$415/$500/$500/$500

* Insureds replacing existing dental coverage may receive up to one year of credit towards the policy benefit requirements. i.e.:- Basic Service benefits are paid at 100% of scheduled amount at policy issue;- Major Services at 50% of scheduled amount for the first policy year, 100% of scheduled amount thereafter; and- TMJ benefits are payable after policy has been in force for one year.