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Plan pricing and coverage for Individuals & Families

How many people need coverage?
Individual Plan
$ 40.11 /MO
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Monthly Premium
$ 134.11 /MO
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$50 deductible ($150 per family)

.

80% COVERAGE / YR
  • 2 cleanings (every 6 mo.)
  • 2 exams (every 6 mo.)
  • 1 set of bitewing x-rays (once per year)
  • Fluoride treatment (through age 18)
  • Panoramic x-ray (once per 5 yr. period)
  • Sealants (through age 13)

ALSO COVERS

  • 60% basic restorative services**
  • 50% other services**
  • ** basic/6 mo. waiting period
  • **major/12 mo. waiting period
  • member annual maximum benefit: $1,200

Individual Plan
$ 47.11 /MO
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Monthly Premium
$ 154.11 /MO
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$50 deductible ($150 per family)

waived for preventive and diagnostic

100% COVERAGE / YR
  • 2 cleanings (every 6 mo.)
  • 2 exams (every 6 mo.)
  • 1 set of bitewing x-rays (once per year)
  • Fluoride treatment (through age 18)
  • Panoramic x-ray (once per 5 yr. period)
  • Sealants (through age 13)

ALSO COVERS

  • 75% basic restorative services**
  • 50% other services**
  • **basic/6 mo. waiting period
  • **major/12 mo. waiting period
  • member annual maximum benefit: $1,200

Individual and Family Dental Plans WI

$0 deductible

.

100% COVERAGE / YR
  • 2 cleanings (every 6 mo.)
  • 2 exams (every 6 mo.)
  • 1 set of bitewing x-rays (once per year)
  • Fluoride treatment (through age 18)
  • 1 annual emergency visit

10% Courtesy Discount on Other Services is offered by Dental Health Associates.

 

Dental Insurance Coverage Gold Plan
Monthly Premium
$ 36.11 /MO
Dental Health Associates of Madison
Monthly Premium
$ 117.11 /MO
Dental Health Associates of Madison

$50 deductible ($150 per family)

.

80% COVERAGE / YR
  • 2 cleanings (every 6 mo.)
  • 2 exams (every 6 mo.)
  • 1 set of bitewing x-rays (once per year)
  • Fluoride treatment (through age 18)
  • Panoramic x-ray (once per 5 yr. period)
  • Sealants (through age 13)

ALSO COVERS

  • 60% basic restorative services**
  • 50% other services**
  • ** basic/6 mo. waiting period
  • **major/12 mo. waiting period
  • member annual maximum benefit: $1,200

Individual and Family Dental Insurance WI
Monthly Premium
$ 42.11 /MO
Dental Health Associates of Madison
Monthly Premium
$ 138.11 /MO
Dental Health Associates of Madison

$50 deductible ($150 per family)

waived for preventive and diagnostic

100% COVERAGE / YR
  • 2 cleanings (every 6 mo.)
  • 2 exams (every 6 mo.)
  • 1 set of bitewing x-rays (once per year)
  • Fluoride treatment (through age 18)
  • Panoramic x-ray (once per 5 yr. period)
  • Sealants (through age 13)

ALSO COVERS

  • 75% basic restorative services**
  • 50% other services**
  • **basic/6 mo. waiting period
  • **major/12 mo. waiting period
  • member annual maximum benefit: $1,200

 

 

    **Waiting periods may be waived if you were covered under an employer-sponsored group policy within 60 days of the start of your coverage under this policy, or an individual policy within 30 days of the start of your coverage under this policy. Momentum Platinum and Gold Plans do not cover oral surgery, implants, orthodontics, or cosmetic services. Contact us for plan details.

     

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