FEE SCHEDULE PLANS PPO PLAN

No Waiting Period available with proof of coverage.†

†To qualify, you must have been enrolled in a plan with similar coverage within 63 days of application date. Proof of similar coverage, with coverage for major services is required.

*Ultimate Max Plans - Out-of-network benefits paid at the in-network negotiated rate. Discounts may also apply for non-covered services.

Individual Dental Insurance

More plans with more benefits and more choices.See any dentist or choose from 200,000+ in-network dentist access points for more savings.*

Value Plan Standard Plan Ultimate Max Plan

Our most economical fee schedule plan. Broad protection at budget pricing. 300+ covered services. Lower monthly premiums than on Standard Plan.

Our basic fee schedule plan, with benefits for 300+ covered services. Higher benefit amounts than our Value Plan.

Our richest annual maximum benefit dental PPO plan with $2,000 per covered person from day one.

Benefit Maximum: $1,000.00 Benefit Maximum: $1,000.00 Benefit Maximum: $2,000.00

Deductible: $50.00 Deductible: $50.00 Deductible: $50.00

Coinsurance: Fixed benefit amounts paid for each service.

Coinsurance: Fixed benefit amounts paid for each service.

Coinsurance: Pays 100% for preventive, 70% for basic and 40% for major services.

Waiting Period: None on preventive services and fillings. 12 months on other services. See schedule for details.

Waiting Period: None on preventive services and fillings. 12 months on other services. See schedule for details.

Waiting Period: None on preventive or basic services. 12 months on major services.

https://www.DentalForAll.com/Agent/PlatinumPerks/Enroll online now

NETWORK HEALTH MEDICARE

NH_OVERVIEW_INDV DNTL _1114Y0108_444_111914 NHIC 11/2014

Policy Form Series IDN-2009 and IDN2013P. Underwritten by Starmount Life Insurance Company and administered by AlwaysCare Benefits, Inc. (a Starmount Life Insurance company). Please Note: A full listing of covered procedures will be provided with your policy. This form is not a contract of insurance. This is a brief description of the plans and should be used only as a guide. It does not contain complete plan details. Terms and conditions, including a complete list of benefits, limitations and exclusions, are defined in the policy issued following enrollment in the plan. If questions arise concerning coverage, the policy will govern. Not available in all states. Rates and benefits may vary by state. Call (800) 309-7682 for state availability.Network Health Medicare Advantage plans include MSA and PPO plans with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal.The products and services described include value-added discounts that are only available to Network Health Medicare Advantage plan members. These discounts are value-added and not part of our Medicare contract or your plan coverage.

8485 Goodwood Blvd. Baton Rouge, LA 70806-7878(800) 309-7682

MORE ABOUT YOUR PLAN

Plus, Receive More Benefits At No Additional Cost to You

` Hearing Savings Plan - 30-60% discounts on major name-brand hearing instruments and accessories.

` Pharmacy Discount Card - Save up to 75% on generic and name-brand prescriptions and more.

When Does Your Coverage Start?

Your coverage start date is determined by the date the application is received.‡

• If your application is received on or before the 25th of the month, coverage will start on the 1st of the next month.

• If your application is received after the 25th of the month, coverage will start on the 1st of the following month.

The first premium payment will be processed immediately. Future premium payments will be processed automatically between the 2nd and 10th of the month for which premium is due.

‡If the initial premium is not successfully processed, you will be notified and coverage will not be put in force.

Optional Vision Rider

Co-Pays Exam (Once per 12 months)Materials

$15$20

Standard Plastic Lenses (Once per 12 months)

Single Vision Bifocal Trifocal Lenticular Progressive

Covered by co-payCovered by co-payCovered by co-pay

$80 allowance$70 allowance

Frames (Once per 12 months)Choose any frame available at provider locations

$120 retail frame allowance

Contact Lenses (Once per 12 months)(Includes fit, follow-up and materials)

In lieu of eyeglass lenses & frames • Elective • Medically necessary

$20 co-pay

Up to $120 retail Up to $210 retail

Out-of-network benefits also available.

Apply Now

SERVICES (IN-NETWORK)

1. Visit https://www.DentalForAll.com/Agent/PlatinumPerks/ or call (800) 309-7682.

2. Pick your plan from five dental options plus a vision rider3. Choose your payment option.