Plan Information


Starmount Ultimate Max 2.0 + Vision Plan Schedule of Covered Services and Copayments

This plan offers you our richest annual maximum— $2,000 per covered person. Members further reduce out-of-pocket costs for any services through our national network of 323,000+ dentist access points.* Services not covered by your plan may still be eligible for in-network discounts from providers who offer discounts.**

Schedule of Covered Services and Copayments

* If you use an out-of-network dentist, benefits are paid based on the network-negotiated rate and you may be billed for any remaining amount up to the billed charge.
** Not an insured benefit.

  Plan Pays
Preventive/Diagnostic
No waiting periods
  • Routine exams and cleanings (2 per 12 months)
    -1 additional cleaning or periodontal maintenance per 12 months if member is in 2nd or 3rd trimester of pregnancy
  • X-rays
    - Bitewing x-rays (1 per 12 months)
    - Full mouth / panoramic x-rays (1 per 5 years)
  • Children’s Services (up to age 14)
    - Fluoride treatment (1 per 12 months)
    - Sealants (1 per 36 months)
  • Adjunctive Pre-Diagnostic Oral Cancer Screening (for age 40+, 1 per 12 months)
100%
Basic Services
No waiting periods
  • Space maintainers (up to age 14, 1 per 24 months)
  • Simple restorative services (Fillings)
  • Simple extractions
  • Emergency treatment
70%
Major Services
12 month waiting period
(6 months in VT)
  • Oral surgery (extractions and impacted teeth) & Anesthesia (subject to review, covered with complex oral surgery)
  • Repair of Crown, Denture, or Bridge
  • Periodontics
  • Endodontics (Root Canals)
  • Inlays and Onlays
  • Crowns, Bridges, Dentures and Endosteal Implants (in lieu of an approved 3-unit bridge)
40%
Deductible
(For Basic and Major Services Only)
Per person, per benefit year.
Maximum 3 per family
$50
$150
Benefit Year Maximums
(Applies to all services)
Per person, per benefit year. $2,000

Insured Vision Plan - Outline of Benefits

Freedom of Choice

We offer a national network of participating vision providers. Our provider panel includes independent optometrists and ophthalmologists, as well as regional and national retail chains (including Walmart Vision Center, Sam’s Club Optical, Costco*, Pearle Vision, Target, Sears, JCPenney and Visionworks). Also, you may choose different providers for vision exam and materials purchases.

Additional Savings! Save on additional pairs of glasses, contact lenses and more! Our Value Added or Service Plus providers offer special negotiated fees and discounts for extra purchases of lenses and coatings, frames, contact lenses and other products

Vision Outline of Benefits
* Special payment and reimbursement terms apply for material purchases at Costco.
  Services
(In-Network)
Out of Network
Allowance

Exams
Materials

$15 Co-pay
$20 Co-pay
Up to $35 Co-pay
See below
Standard Plastic Lenses    
Single Vision
Bifocal
Trifocal
Lenticular
Progressive
Covered by Co-pay
Covered by Co-pay
Covered by Co-pay
$80 Allowance
$70 Allowance
Up to $25
Up to $40
Up to $50
Up to $50
Up to $40
Frames $120 Retail Frame Allowance Up to $50
Contact Lenses
(includes fit, follow-up and materials and are in lieu of frames and lenses)
$20 copay  
Elective
Medically Necessary
$120 Retail Allowance
$210 Retail Allowance
Up to $100 retail
Up to $210 retail

 

Underwritten and administered by Starmount Life Insurance Company. Please Note: A full listing of covered procedures will be provided with your policy. This website is not a contract of insurance. This is a brief description of the plan and should be used only as a guide. It does not contain complete plan details. Terms and conditions, including a complete list of benefits, limitations and exclusions, are defined in the policy issued following enrollment in the plan. If questions arise concerning coverage, the policy will govern. Not available in all states. Rates and benefits may vary by state. Policy form series IDN2016P.

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