Spirit Dental Insurance

The Spirit Core PPO plan helps you cover the costs of dental care. Covered dental services include exams, cleanings, fillings and extractions, as well as crowns, bridges and dentures. Spirit Dental allows you to select your own Ameritas Dental Network provider and a plan that best fits the needs for you and your family. The Ameritas Dental Network is one of the nation’s largest. You save when you use a network provider as these providers have contracted fees (MAC/maximum allowable charge) through their network agreement with Ameritas. When you use a network provider, discounted fees can generally be 25-50% below the average for your area. Visit ameritas.com and select Find a Health Provider to find a provider near you. Simply enter your ZIP Code and choose the Classic (PPO) Network to start your search.

Plan includes a $100 lifetime deductible combined for Preventive, Basic and Major Services. Lifetime deductible is per person covered by the plan.

• Annual Maximum: $1200 Year 1, $1200 Year 2, $1200 Year 3
• Preventive Dental Services: 2 exams per benefit year, 3 cleanings per benefit year paid 100%
• Basic Dental Services: Space maintainers
• Bitewing X-rays (1 per year) Sealants (under age 16) Fluoride (under age 16) (1 per year)  Basic Services are paid 50% year 1, 65% year 2, 80% year 3
• Major Dental Services: Simple extractions, Dental Implants. Diagnostic X-ray (1 per year), full or panoramic in any 3 year period, Oral surgery, Endodontic treatment, Periodontic services, Restoration services; inlays, onlays and crowns, Prosthetic services; bridges and dentures, Basic fillings. Major Services are paid 25% year 1, 50% year 2, 50% year 3
• Ortho Services: Orthodontic care for the proper alignment of teeth is provided only to dependent children who are under 19 when treatment is received. Coverage is 10% year one, 25% year two and 50% year three with a $1,200 lifetime maximum per child.

The Spirit Flex plan helps you cover the costs of dental care. Covered dental services include exams, cleanings, fillings and extractions, as well as crowns, bridges and dentures. This Spirit plan gives you the freedom to use any dentist. The Ameritas Dental Network is one of the nation’s largest. You save when you use a network provider as the providers have contracted fees (MAC/maximum allowable charge) through their network agreement with Ameritas. When you use a network provider, discounted fees can generally be 25-50% below the average for your area. Visit ameritas.com and select Find a Health Provider to find a provider near you. Simply enter your ZIP Code and choose the Classic (PPO) Network to start your search.

Additionally, when you visit a network dental provider your out-of-pocket costs may be lower because the dentists have agreed to a contracted fee for services. You are responsible for any coinsurance and the required deductible. It is important to note that if you receive care from a non-network dentist your out-of-pocket charges will be based on Usual and Customary charges*.

Plan includes a $100 lifetime deductible combined for Preventive, Basic and Major Services. Lifetime deductible is per person covered by the plan.

Spirit Flex | This policy pays for dental expenses for network providers based on the contracted fee (MAC) agreement with Ameritas. Non-network dentists covered dental expenses will be based on Usual and Customary charges after the $100 deductible (combined for Preventive, Basic and Major Services) has been satisfied. The coinsurance percentages are: 100% for Preventive Services, 50% for Basic and 15% for Major. In year two, Basic services increase to 70% and 30% for Major Services. In year three, Basic Services increase to 80% and 40% for Major Services. Your benefit year maximum amount starts in year one at $1,000 and increases to $2,000 year two.

• Annual Maximum: $1,000 Year 1, $2,000 Year 2, $2,000 Year 3
• Preventive Dental Services: 2 exams per benefit year, 2 cleanings per benefit year paid 100%
• Basic Dental Services: Space maintainers, Bitewing X-rays (1 per benefit year) Sealants (under age 16), Fluoride (under age 16) (1 per benefit year), Services are paid 50% year 1, 70% year 2, 80% year 3
• Major Dental Services: Basic fillings, Simple extractions, Diagnostic X-ray (1 per year), full or panoramic in any 3 year period Oral surgery, Endodontic treatment, Periodontic services, Restoration services; inlays, onlays and crowns, Prosthetic services; bridges and dentures. Major Services are paid 15% year 1, 30% year 2, 40% year 3

The Spirit Preferred PPO plan helps you cover the costs of dental care. Covered dental services include exams, cleanings, fillings and extractions, as well as crowns, bridges and dentures. Spirit Dental allows you to select your own Ameritas Dental Network provider and a plan that best fits the needs for you and your family. The Ameritas Dental Network is one of the nation’s largest. You save when you use a network provider as these providers have contracted fees (MAC/maximum allowable charge) through their network agreement with Ameritas. When you use a network provider, discounted fees can generally be 25-50% below the average for your area. Visit ameritas.com and select Find a Health Provider to find a provider near you. Simply enter your ZIP Code and choose the Classic (PPO) Network to start your search.

Plan includes a $100 lifetime deductible combined for Preventive, Basic and Major Services. Lifetime deductible is per person covered by the plan.

• Annual Maximum: $1500 Year 1, $3000 Year 2, $3000 Year 3
• Preventive Dental Services: 2 exams per year, 3 cleanings per benefit year paid 100%
• Basic Dental Services: Bitewing X-rays (1 per benefit year) Basic Services are paid 65% year 1, 100% year 2, 100% year 3
• Major Dental Services: Basic filling, Simple extractions, Dental Implants. Diagnostic X-ray (1 per benefit year), full or panoramic in any 3 year period, Oral surgery, Endodontic treatment, Periodontic services, Restoration services; inlays, onlays and crowns, Prosthetic services; bridges and dentures. Major Services are paid 20% year 1, 50% year 2, 50% year 3
• Hearing Benefits: Benefits are available for hearing exams and hearing aids. Each benefit period you receive up to $75 for eligible hearing exams. The plan pays 50% of the hearing aid cost up to the maximum benefit. The maximum benefit is $200 day 1, $300 after year 1, and $400 after year 2. Five years after using your hearing aid coverage, you are re-eligible for the benefit at the top level. A reduced benefit is available after three years if your current hearing aids can no longer correct your hearing. All benefits assume no break in coverage.

The Spirit Pinnacle PPO plan helps you cover the costs of dental care. Covered dental services include exams, cleanings, fillings and extractions, as well as crowns, bridges and dentures. Spirit Dental allows you to select your own Ameritas Dental Network provider and a plan that best fits the needs for you and your family. The Ameritas Dental Network is one of the nation’s largest. You save when you use a network provider as these providers have contracted fees (MAC/maximum allowable charge) through their network agreement with Ameritas. When you use a network provider, discounted fees can generally be 25-50% below the average for your area. Visit ameritas.com and select Find a Health Provider to find a provider near you. Simply enter your ZIP Code and choose the Classic (PPO) Network to start your search.

Plan includes a $100 lifetime deductible combined for Preventive, Basic and Major Services. Lifetime deductible is per person covered by the plan.

• Annual Maximum: $1200 Year 1, $2500 Year 2, $5000 Year 3
• Preventive Dental Services: 2 exams per benefit year, 3 cleanings per benefit year paid 100%
• Basic Dental Services: Basic fillings, Space maintainers, Bitewing X-rays (1 per benefit year), Sealants (under age 16), Floride (under age 16) 1 per benefit year. Basic Services are paid 50% year 1, 60% year 2, 80% year 3
• Major Dental Services: Simple extractions, Dental Implants. Diagnostic X-ray (1 per year), full or panoramic in any 3 year period, Oral surgery, Endodontic treatment, Periodontic services, Restoration services; inlays, onlays and crowns, Prosthetic services; bridges and dentures. Major Services are paid 25% year 1, 30% year 2, 60% year 3
• Orthodontic Services: Orthodontic care for the proper alignment of teeth is provided only to dependent children who are under 19 when treatment is received. Coverage is 10% year one, 25% year two and 50% year three with a $1,200 lifetime maximum per child.

The Spirit Flex Plus plan helps you cover the costs of dental care. Covered dental services include exams, cleanings,
fillings and extractions, as well as crowns, bridges and dentures. This Spirit plan gives you the freedom to use any
dentist. The Ameritas Dental Network is one of the nation’s largest. You save when you use a network provider
as the providers have contracted fees (MAC/maximum allowable charge) through their network agreement with
Ameritas. When you use a network provider, discounted fees can generally be 25-50% below the average for your
area. Visit ameritas.com and select Find a Health Provider to find a provider near you. Simply enter your ZIP Code
and choose the Classic (PPO) Network to start your search.

Additionally, when you visit a network dental provider your out-of-pocket costs may be lower because the dentists
have agreed to a contracted fee for services. You are responsible for any coinsurance and the required deductible.
It is important to note that if you receive care from a non-network dentist your out-of-pocket charges will be based on Usual and Customary charges*.

Plan includes a $100 lifetime deductible combined for Preventive, Basic and Major Services. Lifetime deductible is
per person covered by the plan.

Spirit Flex Plus | This policy pays for dental expenses for network providers based on the contracted fee (MAC)
agreement with Ameritas. Non-network dentists covered dental expenses will be based on Usual and Customary
charges after the $100 deductible (combined for Preventive, Basic and Major Services) has been satisfied. The
coinsurance percentages are: 100% for Preventive Services, 50% for Basic and 20% for Major. In year two, Basic
services increase to 70% and 40% for Major Services. In year three, Basic Services increase to 80% and 50% for
Major Services. Your benefit year maximum amount starts in year one at $1,500 and increases to $2,500 year two
and thereafter.

• Annual Maximum: $1,500 Year 1, $2,500 Year 2, $2,500 Year 3
• Preventive Dental Services: 2 exams per benefit year, 3 cleanings per benefit year paid 100%
• Basic Dental Services: Basic fillings, Space maintainers, Bitewing X-rays (1 per Benefit year), Sealants (under age 16), Fluoride (under age 16) (1 per benefit year). Services are paid 50% year 1, 70% year 2, 80% year 3
• Major Dental Services: Simple extractions, Diagnostic X-ray (1 per benefit year), full or panoramic in any 3 year period, Oral surgery, Endodontic treatment Periodontic services, Restoration services; inlays, onlays and crowns, Prosthetic services; bridges and dentures. Major Services are paid 20% year 1, 40% year 2, 50% year 3

• Annual Maximum: $1200 Year 1, $1200 Year 2, $1200 Year 3
• Preventative Dental Services: 2 exams per benefit year, 3 cleanings per benefit year paid 100%
• Basic Dental Services: Space maintainers
• Bitewing X-rays (1 per year) Sealants (under age 16) Fluoride (under age 16) (1 per year)  Basic Services are paid 50% year 1, 65% year 2, 80% year 3
• Major Dental Services: Simple extractions, Dental Implants. Diagnostic X-ray (1 per year), full or panoramic in any 3 year period, Oral surgery, Endodontic treatment, Periodontic services, Restoration services; inlays, onlays and crowns, Prosthetic services; bridges and dentures, Basic fillings. Major Services are paid 25% year 1, 50% year 2, 50% year 3
• Ortho Services: Orthodontic care for the proper alignment of teeth is provided only to dependent children who are under 19 when treatment is received. Coverage is 10% year one, 25% year two and 50% year three with a $1,200 lifetime maximum per child.

• Annual Maximum: $1,000 Year 1, $2,000Year 2, $2,000Year 3
• Preventative Dental Services: 2 exams per benefit year, 2 cleanings per benefit year paid 100%
• Basic Dental Services: Space maintainers, Bitewing X-rays (1 per benefit year) Sealants (under age 16), Fluoride (under age 16) (1 per benefit year), Services are paid 50% year 1, 70% year 2, 80% year 3
• Major Dental Services: Basic fillings, Simple extractions, Diagnostic X-ray (1 per year), full or panoramic in any 3 year period Oral surgery, Endodontic treatment, Periodontic services, Restoration services; inlays, onlays and crowns, Prosthetic services; bridges and dentures. Major Services are paid 15% year 1, 30% year 2, 40% year 3

• Annual Maximum: $1500 Year 1, $3000 Year 2, $3000 Year 3
• Preventative Dental Services: 2 exams per year, 3 cleanings per benefit year paid 100%
• Basic Dental Services: Bitewing X-rays (1 per benefit year) Basic Services are paid 65% year 1, 100% year 2, 100% year 3
• Major Dental Services: Basic filling, Simple extractions, Dental Implants. Diagnostic X-ray (1 per benefit year), full or panoramic in any 3 year period, Oral surgery, Endodontic treatment, Periodontic services, Restoration services; inlays, onlays and crowns, Prosthetic services; bridges and dentures. Major Services are paid 20% year 1, 50% year 2, 50% year 3
• Hearing Benefits: Benefits are available for hearing exams and hearing aids. Each benefit period you receive up to $75 for eligible hearing exams. The plan pays 50% of the hearing aid cost up to the maximum benefit. The maximum benefit is $200 day 1, $300 after year 1, and $400 after year 2. Five years after using your hearing aid coverage, you are re-eligible for the benefit at the top level. A reduced benefit is available after three years if your current hearing aids can no longer correct your hearing. All benefits assume no break in coverage.

• Annual Maximum: $1200 Year 1, $2500 Year 2, $5000 Year 3
• Preventative Dental Services: 2 exams per benefit year, 3 cleanings per benefit year paid 100%
• Basic Dental Services: Basic fillings, Space maintainers, Bitewing X-rays (1 per benefit year), Sealants (under age 16), Floride (under age 16) 1 per benefit year. Basic Services are paid 50% year 1, 60% year 2, 80% year 3
• Major Dental Services: Simple extractions, Dental Implants. Diagnostic X-ray (1 per year), full or panoramic in any 3 year period, Oral surgery, Endodontic treatment, Periodontic services, Restoration services; inlays, onlays and crowns, Prosthetic services; bridges and dentures. Major Services are paid 25% year 1, 30% year 2, 60% year 3
• Orthodontic Services: Orthodontic care for the proper alignment of teeth is provided only to dependent children who are under 19 when treatment is received. Coverage is 10% year one, 25% year two and 50% year three with a $1,200 lifetime maximum per child.

• Annual Maximum: $1,500 Year 1, $2,500Year 2, $2,500Year 3
• Preventative Dental Services: 2 exams per benefit year, 3 cleanings per benefit year paid 100%
• Basic Dental Services: Basic fillings, Space maintainers, Bitewing X-rays (1 per Benefit year), Sealants (under age 16), Fluoride (under age 16) (1 per benefit year). Services are paid 50% year 1, 70% year 2, 80% year 3
• Major Dental Services: Simple extractions, Diagnostic X-ray (1 per benefit year), full or panoramic in any 3 year period, Oral surgery, Endodontic treatment Periodontic services, Restoration services; inlays, onlays and crowns, Prosthetic services; bridges and dentures. Major Services are paid 20% year 1, 40% year 2, 50% year 3