A. Enrollment and Eligibility
Coverage is available for individuals age 19+. Separate rates apply for individuals 65+ who apply for coverage. You may elect individual only, individual + spouse, individual + children or individual + family coverage. Dependent eligibility may vary by state, please click here to view the State Eligibility Requirements.
B. Your Effective Date
The coverage start date is the 1st of the month and is determined by the date the completed application is received subject to the initial premium being paid. If the initial premium is not successfully processed, you will be notified and coverage will not be put in force.
- If the application is received on or before the 25th of the month, coverage will start on the 1st of the next month. For example, if we receive the application on November 15th coverage will be effective December 1st.
- If the application is received after the 25th of the month, coverage will start on the 1st of the following month. For example, if we receive the application on November 26th coverage will be effective January 1st.
C. How does the dental plan work?
The plan pays a flat dollar amount per dental procedure based on the fee schedule in the policy. We will pay the lesser of the provider’s actual charge or the amount listed on the Schedule of Covered Dental Procedures, subject to policy year deductible, annual maximum, and limitations and exclusions.
D. What does the vision plan include?
The vision plan is a fully insured plan that provides coverage for a comprehensive eye exam and materials purchases once per 12 months. There are low co-pays for your exam and materials with generous in-network allowances for the purchase of frames or contact lenses. Frames are covered up to the retail allowance and you may choose any frame available. In lieu of frames and lenses, you may use the available retail allowance to purchase contact lenses that include your fit, follow-up and materials.
E. Dental Annual Deductible & Calendar Year Maximums
There is a $50 annual deductible per person ($150 maximum per family) and a $1,000 per person per benefit year maximum. The annual deductible does not apply to preventive services.
F. Choice of Provider
Members may choose any dental or vision provider or visit an in-network provider and pay even less. Our dental network consists of over 180,000 access points nationally for your convenience. Our large vision network consists of independent providers as well as retail locations including Walmart, Sam’s Club, Pearle Vision, JCPenney, Sears, Target, Costco, and EyeMasters.
G. Coordination of Benefits
Yes, we do coordinate benefits. The policy that has been in-force the longest period of time will be considered the primary policy. We will request EOB’s from the primary carrier to determine the paid amount and any remaining balance will be paid up to our scheduled amount listed in the policy. We will not exceed the lesser of the scheduled amount or the billed amount.
H. Cancellation Policy
Request for cancellation may be submitted by emailing email@example.com, calling Customer Service or mailing your request to 8485 Goodwood Boulevard, Baton Rouge, LA 70806. The effective date of termination will be the last day of the month for which premium is paid.
I. Termination of Policy
Coverage terminates on the earliest of the following dates:
- the last day of the month in which you cease to be eligible for coverage;
- the last day of the month in which your dependent is no longer a dependent as defined in the policy
- subject to the grace period, the last day of the month for which a premium has been paid by you or on your behalf.
- or the date the policy ends.
J. Dental Exclusions/Limitations
The policy does not cover losses caused by or resulting from any of the following. In addition, the procedures listed below will not be recognized toward satisfaction of any Policy Year Deductible. <br />
- The policy does not cover losses caused by or resulting from any of the following. In addition, the procedures listed below will not be recognized toward satisfaction of any Policy Year Deductible.
- Any procedure or service not shown on the Schedule of Covered Procedures or the Policy Schedule.
- Amounts in excess of the Policy Year Benefit Maximum.
- Services or supplies we consider being experimental or investigative.
- Any injury or illness when covered under Worker’s Compensation or similar law, or which is work related.
- Services received before a Covered Person’s effective date, including started but not completed services.
- Services received after, or started but not completed within 30 days of a Covered Person’s coverage ending.
- Charges for dental services performed by other than a licensed dentist or dental hygienist.
- Services that are not recommended by a dentist or that are not required for the preservation or restoration of oral health.
- Repairs or adjustments to dental work within six months of the initial work.
- Replacement prosthetics within seven years of last placement.
- Treatment involving crowns for a given tooth within seven years of last placement, regardless of the type of crown.
- Replacement for inlays or onlays for a given tooth within seven years of last placement.
- Any services performed for convenience or cosmetic purposes.
- Any charge for a service required as a result of disease or injury that is due to war or an act of war (whether declared or undeclared); taking part in an insurrection or riot.
- ILLEGAL OCCUPATION: The insurer shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation.
- Services performed by a Dentist who is a member of the covered person’s Immediate Family.
- No benefits will be paid for replacement of teeth missing prior to the effective date of coverage.
- No benefits will be paid for the initial placement of removable full or partial dentures, unless it includes the replacement of a Functioning Natural Tooth extracted while the covered person is insured under the policy.
- No benefits will be paid for the initial placement of a fixed partial denture including a Maryland Bridge, unless it includes the replacement of a Functioning Natural Tooth extracted while the covered person is insured under the policy.
- Federal, State or local taxes are not included as part of a Covered Dental Expense.
- See the Schedule of Covered Dental Procedures in the policy for all specific procedure limitations.
K. Vision Limitations/Exclusions
The Contact Lenses benefit is paid in lieu of Eyeglass Lenses and Frames. A Covered Person is eligible to receive benefits under the Eyeglass Lenses Benefit or the Frame benefit only after the Contact Lenses benefit Frequency has ended.
The Eyeglass Lenses benefit and the Eyeglass Frame benefit is paid in lieu of the Contact Lenses benefit. A Covered Person is eligible to receive benefits under the Contact Lenses benefit only after the Eyeglass Lenses benefit Frequency has ended.
Dilation is covered in full under the Vision Exam benefit ONLY if done for one of the following conditions: central vision loss, photopsia, floaters, high myopia, diabetes or history of ocular surgery, ocular trauma or ocular disease.
No benefits are payable for the any of the following conditions, procedures and/or materials, unless otherwise specifically listed as a covered benefit in the Policy Schedule:
- Replacement frames and/or lenses, except at normal intervals when covered services are otherwise available;
- Plano or non-prescription lenses or sunglasses;
- Orthoptics, vision training and any associated supplemental testing;
- Frame cases;
- Low (subnormal) vision aids or aniseikonic lenses;
- Medical and surgical treatment of the eyes;
- Charges incurred after (a) the Policy ends; or (b) the Insured’s coverage under the Policy ends, except as stated in the Policy;
- Experimental or non-conventional treatment or device;
- Any eye examination or corrective eyewear required by an Employer as a condition of employment;
- Services and materials provided by another vision plan except in the case of Coordination of Benefits;
- Services for which benefits are paid by Worker’s Compensation;
- Benefits provided under the employee’s medical insurance except in the case of Coordination of Benefits;
- Blended bifocal lenses
- Groove, Drill or Notch, and Roll and Polish;
- Two pairs of glasses, in lieu of bifocals, trifocals or progressives;
- Coating on lenses (Factory scratch coat, anti-reflective, sunglass colors, etc.)
- Cosmetic items;
- Faceted lenses
- High-Index Lenses
- Laminated Lenses
- Oversize Lenses – any lens with an eye size of 61mm or greater
- Photochromic (Transition) lenses
- Polaroid lenses
- Polished bevel lenses
- Polycarbonate lenses
IDNVR-2009 (AZ) Page 22 of 22 Version 3.0
- Prism lenses
- Slab-off lenses
- Ultra-violet tint or coating
- Additional cost for contact lenses over the allowance
- Additional cost for a frame over the allowance
- Regardless of optical necessity, the Vision Examination Benefit is not available more frequently than specified in the Schedule of Benefits.
- Services received before Your effective date, including started but not completed services.
- Charges for services rendered by a provider other than Ophthalmologist or Optometrist acting within the scope of his or her license.
- Treatment or services received while outside the territorial limits of the United States.
- Any charge for a service required as a result of disease or injury that is due to war or an act of war (whether declared or undeclared); taking part in an insurrection or riot; the commission or attempted commission of a crime; an intentionally self-inflicted injury or attempted suicide while sane or insane.
- Federal, State or local taxes
- Progressive Power Lenses*
*Progressive Power Lens Benefit. If this type of lens is not a covered benefit under your Certificate, the Provider will apply the retail charge for standard trifocal lenses against the charge for the style of progressive lens You have selected. You pay the Provider the difference, if any, between the two.
L. Grievance Procedures
If you or one of your eligible dependents has a complaint with Starmount Life Insurance or your dentist, you may register a Complaint by calling Customer Service at 1-888-729-5433, Ext. 2013.
This is a brief description of the individual dental plan. A full explanation of benefits, limitations and exclusions is contained in the policy issued when coverage becomes effective. Policy Form Series IDN-2009. Underwritten and administered by Starmount Life Insurance Company.
*Subject to policy deductible, annual maximum and limitations and exclusions. Waiting periods do not apply in Washington.