Premier Select 1500
Plan Information

A. Enrollment and Eligibility

Coverage is offered to individuals under 65 years of age plus their eligible dependents. For individuals age 65 years and older plus their eligible dependents coverage is offered at an increased rate. Final rate will be calculated when completing your application.

Your Eligible Dependents are your:

  • Spouse; and
  • Unmarried dependent children under age 26

B. Your Effective Date

Plan effective dates are always the 1st of the month. If the enrollment form and payment information are received by the 5th of the month, coverage will become effective on the 1st of the same month. Otherwise, the coverage will not start until the 1st day of next month.  Incomplete enrollment forms or failure to submit the required initial premium amount may cause an initial delay in issuance of insurance. Do not cancel any other insurance or assume you are insured under the Plan until you receive your certificate of insurance.

C. How does the Premier Select 1500 plan work?

As long as you meet the plan’s general eligibility requirements and pay the applicable premium, your acceptance is automatic. This plan contains waiting periods that must be satisfied before coverage is available for services. 12 months waiting period for Major Services and no waiting periods for Preventive and Basic Services. The Plan helps pay the cost of most dental care services, including exams, cleanings, fillings, extractions, crowns, bridges, and dentures.

D. Annual Deductible & Calendar Year Maximums

The Calendar Year Deductible is the amount of covered dental charges incurred by an insured person or on behalf of your insured dependent before Nationwide Multiflex Dental starts paying benefits. The Premier Select 1500 plan offers an annual deductible of $100 per person, $300 per family. Deductible for Preventive/Diagnostic services is waived if In-Network provider is used. The Calendar Year Maximum is the maximum amount payable for all eligible dental expenses in any calendar year as shown on the Fee Schedule. The annual maximum for this plan is $1500, per person.

E. Choice of Provider

While you are free to see any dentist you choose, out‐of‐network benefits will be paid based on MAC fees which is the Maximum Allowable Charge of a pre‐determined fee schedule used to pay out‐of‐network claims. You may be responsible for the difference between the MAC and the actual dental charge from a out‐of‐network provider. Using an out‐of‐network provider will result in decreased savings on your dental services.

F. Emergency Dental Services

Claims are paid the same as for non-emergency services.

G. Coordination of Benefits

Benefits will be adjusted so that the total payment under all Plans is no more than 100 percent of the Insured’s Allowable Expense. In no event will total benefits paid exceed the total payable in the absence of Coordination of Benefits.

H. Cancellation Policy

You may cancel your policy at any time by notifying Member Services of your request in writing. The premium will be refunded only if cancelled within the first 30 days of enrollment. The $10 Admin Fee and $3 NSBA Fee are non-refundable.

I. Termination of Policy

Coverage terminates on the earliest of the following dates:

  1. the last day of the month in which you cease to be eligible for coverage;
  2. the last day of the month in which your dependent is no longer a dependent as defined
  3. subject to the grace period, the last day of the month for which a premium has been paid by you or on your behalf.
  4. or the date the master policy ends.

J. Exclusions/Limitations

No Benefits are payable under the Policy for the Services listed below. In addition, the Services listed below will not be recognized toward the satisfaction of any deductible:

  1. Any Services which are not included in the Schedule of Covered Procedures;
  2. Any Service started or appliance installed before the Effective Date or after the Termination Date, except in those instances noted in this Certificate
  3. Crowns, inlays, onlays, cast restorations, or other laboratory prepared restorations on teeth, which may be satisfactorily restored with an amalgam or composite resin filling;
  4. Any treatment which is elective or primarily cosmetic in nature, as well as, any replacement of prior cosmetic restorations unless such procedure is listed in the Schedule of Covered Procedures;
  5. Appliances, Services or procedures relating to:
    1. the change or maintenance of vertical dimension;
    2. restoration of occlusion (unless otherwise noted in the Schedule of Covered Procedures—only for occlusal guards);
    3. splinting;
    4. correction of attrition, abrasion, erosion or abfraction;
    5. bite registration; or
    6. bite analysis;
  6. Replacement of bridges unless the bridge is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
  7. Replacement of full or partial dentures unless the prosthetic appliance is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
  8. Replacement of crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
  9. For Orthodontia Services;
  10. Services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain unless such procedure is listed as a Covered Procedure in the Schedule of Covered Procedures;
  11. Charges for implants of any type, and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized Services or attachments unless such procedures are listed as Covered Procedures in the Schedule of Covered Procedures;
  12. Athletic mouth guards; myofunctional therapy; treatment for malignancies, cysts and neoplasms; failure to keep scheduled appointment; charges for completion of Claim forms, precision or semi-precision attachments; denture duplication; oral hygiene instruction; separate charges for acid etch; charges for travel time; transportation costs; professional advice; treatment of jaw fractures; orthognathic surgery; exams required by a third party other than Us, personal supplies (e.g., water pik, toothbrush, floss holder, etc.); or replacement of lost or stolen appliances;
  13. Prescription drugs, premedication, pharmaceuticals, or analgesia;
  14. Dental defect or injury caused by a declared or undeclared war or any act of war or terrorism or taking part in an insurrection or riot; the commission or attempted commission of a felony; engaging in an illegal occupation; an intentionally self-inflicted injury or attempted suicide while sane or insane;
  15. Any charge for a Service for which benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, even if You did not purchase the coverage that is available to You;
  16. Any charge for a Service performed outside of the United States other than for Emergency Treatment. Benefits for Emergency Treatment performed outside of the United States are limited to a maximum of $100 per Plan Year;
  17. The initial placement of a removable full denture or a removable partial denture unless it includes the replacement of a Natural Tooth extracted while the Person is insured under the Policy;
  18. The initial placement of a fixed partial denture including a Maryland Bridge, unless it includes the replacement of a Natural Tooth extracted while the Person is insured under the Policy, provided that tooth was not an abutment to an existing partial denture. Frequency Limitations for replacement of dentures and bridges are stated in the Schedule of Covered Procedures. Benefits are payable only for the replacement of those teeth which were extracted while the Person was insured under the Policy;
  19. The replacement of teeth beyond the normal complement of 32;
  20. The replacement of an existing removable partial denture with a fixed partial denture unless upgrading to a fixed partial denture is essential to the correction of the Covered Person's dental condition;
  21. Local anesthetic, including light anesthetic, as a separate fee;
  22. Any Treatment Plan which involves full-mouth reconstruction by the removal and reestablishment of occlusal contacts of 10 or more teeth with restorations, crowns, onlays, inlays, fixed partial dentures, dentures, or any combination of these Services;
  23. Services with respect to congenital (hereditary) or developmental (before birth) malformations, except during the 31 day period immediately following the birth of Your Child, including but not limited to; cleft palate, maxillary and mandibular (upper and lower) malformations, enamel hypoplasia (lack of development), fluorosis, and anodontia;
  24. Dental care paid for, required, or provided by or under the laws of a national, state, local or provincial government, or treatment furnished within a hospital or other facility owned or operated by a national or state government unless the Insured Person has a legal obligation to pay;
  25. Dental services performed in a hospital and related hospital fees;
  26. Services covered under an existing medical plan;
  27. The portion of an expense which is in excess of the Reasonable Charge;
  28. Fees associated with a cancelled or missed appointment;
  29. General anesthesia and I.V. sedation, unless deemed medically necessary as determined by the following definition. “Medically necessary” means that the general anesthesia and I.V. sedation which meets all of the following:
    1. Required to meet the health care needs of the Claimant; and
    2. Consistent (in scope, duration, intensity and frequency of treatment) with scientifically based guidelines of the American Dental Association or research organizations or governmental agencies; and
    3. Consistent with the diagnosis of the covered dental procedure; and
    4. Required for reasons other than the comfort or convenience of the Claimant.

Missing Teeth Limitation: We will not pay benefits for replacement of teeth missing on a Covered Person’s Effective Date of insurance under this Certificate for the purpose of the initial placement of a full denture, partial denture or fixed bridge. In addition, such replacement will not be recognized toward the satisfaction of any Deductible. However, expenses for the replacement of teeth missing on the Effective Date will be considered for payment as follows:

  1. The initial placement of full or partial dentures will be considered a Covered Procedure if the placement includes the initial replacement of a Natural Tooth extracted while the Covered Person is covered under the Group Policy;
  2. The initial placement of a fixed bridge will be considered a Covered Procedure if the placement includes the initial replacement of a Natural Tooth extracted while a Covered Person is covered under the policy. However, the following restrictions will apply:
    1. Benefits will only be paid for the replacement of the teeth extracted while a Covered Person is covered under the Group Policy;
    2. Benefits will not be paid for the replacement of other teeth which were missing on the Covered Person’s Effective Date.
    3. Missing teeth limitation will be waived after a Covered Person has been covered under the plan for (3) three continuous years unless it is a replacement of an existing unserviceable prosthesis.

K. Grievance Procedures

If you or one of your eligible dependents has a complaint with Nationwide Multiflex Dental or your dentist, you may register a Complaint by calling Member Services.

L. Disclaimer

This is a general summary of the features of the Nationwide Multiflex Dental plan issued. When you purchase the plan you will receive a Certificate of Insurance that details your rights and obligations, as well as those of the insurance company.

This website provides a very brief description of some of the important features of this plan. It is not the insurance contract, nor does it represent the insurance contract. A full description of benefits, exceptions and limitations is contained in the Certificate of Insurance.