| Underwritten by Fidelity Security Life
Insurance Company
Brief Plan Summary:
Preventive Services - Class A 100%
UCR with NO waiting periods
- Exams
- Cleanings
- Fluoride (Child to age 16)
Basic Services - Class B
80% - UCR with 6 months waiting period
- X-rays
- Fillings
- Simple Extractions
Major Services - Class C
50% - UCR with 12 month waiting period
- Endodontics
- Oral Surgery (Surgical Extractions &
Impactions)
- Periodontics
Major Services - Class D
50% - UCR with 24 month waiting period
Deductibles
- $35 lifetime - Class A
- $50 calendar year – Class B,C, & D
combined
Additional Information
- Calendar Yr Max $1000
- 12 month rate guarantee
State
|
Zip Code |
Area
|
Rates (includes $2.00 non-commissionable
admin. fee)
|
 |
|
|
Applicant Only
|
Applicant + Dep.
|
Applicant + Family
|
| NV |
Other |
3
|
$ 26.93
|
$ 49.37
|
$ 75.54
|
|
890-891 |
4
|
$ 29.17
|
$ 53.63
|
$ 82.16
|
|
893-894 |
4
|
$ 29.17
|
$ 53.63
|
$ 82.16
|
|
895-897 |
4
|
$ 29.17
|
$ 53.63
|
$ 82.16
|
| KY |
All Zips |
2
|
$ 24.69
|
$ 45.10
|
$ 68.92
|
| OH |
Other |
2
|
$ 24.69
|
$ 45.10
|
$ 68.92
|
| |
440-444 |
3
|
$ 26.93
|
$ 49.37
|
$ 75.54
|
|
