The PPO plans, underwritten by Assurant Employee Benefits, are by ktz54195

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									The PPO plans, underwritten by Assurant Employee Benefits, are called the Freedom Preferred plans.
There is a High and a Low Option. These plans provide a variety of benefits, under which you and your
family have the freedom to use any dentist or specialist anywhere. If you choose to use an in network
dentist, you will pay your deductible when applicable and the coinsurance that corresponds to your
procedure. If you choose a non network provider, then you will be balanced billed by that dentist.

With both plans you have $1,000 in benefits for each covered member available to use each plan year
(Nov. 1 – Oct. 31). Once Assurant has paid out this maximum, you will be responsible for 100% of the
costs thereafter.

The High Option offers child orthodontia coverage for children under the age of 19 that are not currently
undergoing treatment. The orthodontia benefit pays 50% of the first $2,000 of treatment. Costs above
this are the covered member’s responsibility.

Claim payments for non network providers may be made to you or your dentist, whichever you prefer,
unless benefits have been assigned to the provider. If you use a non participating provider your cost will
be higher because Assurant has negotiated discounts on your behalf with their participating providers.

If you are having services in excess of $300 your provider must submit their treatment plan to Assurant
for benefit determination.

Freedom PPO Plan Features:
     •    Freedom to chose any dentist, including specialist
     •    Nationwide coverage
     •    Fast and accurate claims service
     •    No referrals required
     •    Treatment plan benefit determination for services over $300

Visit Assurant’s website at www.assurantemployeebenefits.com for more information on participating dentists in your area or contact
customer service at 1-800-442-7742.


Freedom PPO Dental Plans:

                                              Freedom Preferred         Freedom Preferred
Plan Summary                                     Low Option                High Option
                                                              In Network Benefits:

Deductible                                           $50 per person                        $50 per person
                Waived for Preventive                     Yes                                   Yes

Coinsurance (Plan Pays)
            Preventive Services                          100%                        100%
            Basic Services                                90%                         90%
            Major Services                                30%                         60%
            Orthodontic Services                      Not Covered                     50%
Plan Year Maximum                                        $1,000                     $1,000
Lifetime Orthodontia Maximum                          Not Covered                   $1,000
                                                               Out of Network Benefits:
Deductible                                           $50 per person             $50 per person
          Waived for Preventive                           Yes                         Yes
Coinsurance (Plan Pays)
          Preventive Services                             100%                                   100%
          Basic Services                                   80%                                    80%
          Major Services                                   10%                                    50%
          Orthodontic Services                         Not Covered                                50%

Plan Year Maximum                                        $1,000                                 $1,000
Lifetime Orthodontia Maximum                           Not Covered                              $1,000
                                                                Additional Plan Specifications:

                                                             Major
Endodontics & Periodontics                                                                          Major
                                                               90th
Usual & Customary Percentile                                                                          90th
Maximum Allowable                              20% off the 80th Percentile             20% off the 80th Percentile


Limitations and Exclusions
No benefits are payable for: natural teeth missing on date of insurance; care that is not necessary or not
listed under the Schedule of Dental services in your group Policy; not professionally endorsed;
experimental or cosmetic in nature; care for which there is no legal obligation to pay; not incurred while
insured; work related; TMJ disorders; orthodontics (on the Freedom Low plan); implants; vertical
dimension; bite registration; emergency oral exam; loss due to war, riot, felony, or assault.

Benefit Adjustments
Benefits will be coordinated with any other dental coverage. Under the Alternative Treatment provision,
benefits will be payable for the most economical services or supplies meeting broadly accepted standards
of dental care. If the cost of a proposed Dental Treatment Plan exceeds $300, it should be submitted to
Assurant Employee Benefits for an estimate of benefits payable.

Eligibility
Full-time employees, spouses, and unmarried, dependent children (up to age 25).

This is a brief description only. It is not a Certificate of Coverage. Please see the Group Policy for a complete list of covered dental
services and the Maximum Covered Expense. The Group policy alone determines all rights, benefits, and applicable Limitations and
Exclusions.

								
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