Dental Insurance - American Health Shield Plan B Details

Renaissance Life & Health Insurance Company of America

Renaissance Classic
Summary of Dental Insurance - Plan B Summary
For Group#8800
American Travel Services Trust

This Summary of Dental Plan Benefits should be read in conjunction with your Dental Care Certificate. Your Dental Care Certificate will provide you with additional information about your Renaissance Dental Plan, including information about plan exclusions and limitations.

Benefit Year – 12 month period beginning with covered person’s effective date.

Covered Services -	RLHICA Pays		You Pay
Per Visit Deductible Office Visit			$20
Class I Benefits
Diagnostic and Preventive Services - Used to evaluate existing conditions and/or to prevent dental abnormalities or disease (two allowed in any benefit year - includes exams, cleanings, bitewing x-rays and fluoride treatments)		50%	50%
Class II Benefits
Emergency Palliative Treatment - Used to temporarily relieve pain		50%	50%
Radiographs/Diagnostic Imaging - X-rays as required for routine care or as necessary for the diagnosis of a specific condition		50%	50%
Minor Restorative Services – Used to repair teeth damaged by disease or injury (for example, silver fillings and white fillings)		50%	50%
Simple Extractions – Simple extractions including local anesthesia, suturing, if needed and routine post-operative care		50%	50%
Sealants – Sealants for the occlusal surface of first and second permanent molars		not covered	not covered
Periodontal Maintenance – Periodontal maintenance following active periodontal therapy		50%	50%
After Hour Visits – Services performed during after hours visits by a dentist		50%	50%
Consultations – Benefits for consultations by a dentist other than the practitioner providing treatment		50%	50%
Class III Benefits
Oral Surgery Services – Extractions and dental surgery, including local anesthesia, suturing, if needed, and routine post-operative care		50%	50%
Endodontic Services – Used to treat teeth with diseased or damaged nerves (for example, root canals)		50%	50%
Periodontic Services – Used to treat diseases of the gums and supporting structures of the teeth		50%	50%
Major Restorative Services – Used when teeth can't be restored with another filling material (for example, crowns)		50%	50%
Prosthodontic Services – Used to replace missing natural teeth (for example, bridges, dentures, and implant services)		50%	50%
Relines and Repairs – Relines and repairs to bridges, removable bridges, partial dentures, and complete dentures		50%	50%
Occlusal Guards – Benefits for occlusal guards, and limited occlusal adjustments		50%	50%
Office Visits – Office visits during regularly scheduled hours		50%	50%
Class IV Benefits
Orthodontic Services – Services, treatment, and procedures to correct malposed teeth including Orthodontic Services for Children to the age of 19		50%	50%

Method of Benefit Payment – Benefit payment will be based on the Allowed Amount method of payment. If the Submitted Amount is more than the Allowed Amount, the Certificate Holder is not only responsible for paying the Dentist that percentage of the Allowed Amount listed in the “You Pay” column, but is also responsible for paying the Dentist the difference between the Submitted Amount and the Allowed Amount. RLHICA determines Allowed Amount based upon treatment rendered and the periodically determined 80th percentile of fees charged by a sample of Dentists of similar training within your geographic area.

Maximum Payment – $1250 per person total per Benefit Year on Class I, Class II and Class III Benefits collectively.

$ 1000 per person total per Lifetime on Class IV Benefits.

Deductible - $20 per office visit per person.

Waiting Period – All Certificate Holders (and their Dependents, if covered above) will be eligible for coverage for Class II Benefits 6 months following the effective date of the Certificate Holder or Dependent.

All Certificate Holders (and their dependents, if covered above) will be eligible for coverage for Class III Benefits 12 months following the effective date of the Certificate Holder or Dependent.

All Dependents under age 19, (if covered above) will be eligible for coverage for Class IV Benefits 24 months following the date the dependent enrolled.

Eligible People – All bonafide members of the American Travel Services Trust. Also eligible are your legal spouse, your dependent unmarried children to the end of the calendar year in which they turn 19 or your unmarried children who have not reached their 25th birthday, if the child is (1) dependent upon you for support and (2) living in your household.

Where two certificate holders are eligible under the same group and are legally married to each other, they will be enrolled under one application card and will receive benefits under a single policy without coordination of benefits under the RLHICA Dental policy.

The Certificate Holder pays the full cost of this plan.

Benefits will cease on the last day of the month in which the employee is terminated, subject to all applicable laws or regulations.

Renaissance Dental enrollees are eligible to receive discounts on vision, hearing and pharmacy services when they utilize participating service providers. These additional benefits are available at no added cost.

VISION CARE SERVICES provided by EyeMed Vision CareSM	MEMBER BENEFIT
Complete Glasses Purchase (frame, lens, lens options purchased in same transaction)
Standard Plastic Lenses including Standard Scratch Single Vision Bifocal Trifocal	$ 75 $ 95 $125
Frames (unlimited selection)	30% off retail price
Lens Options Standard UV Standard Tint Standard Polycarbonate Standard Antireflective Coating Standard Progressive (add-on to bifocal)	$15 $15 $40 $45 $70
Contact Lenses (conventional, materials only)	15% off retail price
Lasik or PRK	15% off retail price or, 5% off promotional price
Frequency Examination Frames Lenses Contact Lenses	Unlimited Unlimited Unlimited Unlimited
HEARING CARE SERVICES provided by Beltone™	MEMBER BENEFIT
Hearing Aids and related services	15% discount off retail price
PHARMACY CARE SERVICES provided by Caremark®	MEMBER BENEFIT
Discounts at participating pharmacies	20% average discount off retail price

The Renaissance, Beltone, Caremark, and EyeMed names, logos, trademarks, service marks, and domain names (collectively “Marks”) referenced above are the property of the Renaissance family of companies or their respective owners. Use of these Marks without the express written permission of Renaissance or the third party owners of the Marks is prohibited. All Rights Reserved.

Long Term Consumer Care, Inc.
N27 W23960 Paul Road Suite 201 ~ Pewaukee, WI 53072
Toll Free: 1.800.544.9505 Fax: 1-262.523-1910