Specialists
You Pay Same As General Dentist
Waiting Periods
50%
Orthodontics
Children (up to age 19)
50%
50%
25% Discount
Orthodontics
Discount (All Members)
25% Discount
25% Discount
Preventive
None
EMI CHOICE PPO HIGH PLAN
50%
Major
Crowns, bridge, dentures, inlays, periodontics, endodontics, oral surgery and Implants (1)
50%
50%
80%
Basic
Simple extractions and fillings
80%
80%
In-Network
(Advantage Plus)
100%
Preventive
Office visit, cleaning, oral exam and x-rays
In-Network
(Premier Network)
50%
Out-of-Network
50%
Summary
of
Benefits
$1,000
$58
Subscriber
Subscriber + 1
Subscriber + 2
Subscriber + 3
Subscriber + 4 or more
$31
$94
$76
$129
Monthly
Affinity
Rates
Major
15 Month Waiting Period
Orthodontics
24 Month Waiting Period
Deductible (applies to Preventive, Basic, and Major
$25
Individual
$50
$50
Maximums
$1,500
Annual Max per Person
$1,000
Major Annual Max
Family Max
$750
Ortho Lifetime Max
(Medically / Non Medically Necessary)
$75
$150
$150
Advantage
Network / Reimbursement schedule
Premier
Premier
Basic
6 Month Waiting Period
Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions. All Services are subject to the EMI Health fee schedule, which is subject to charge on January 1st each year.. When using a Non-participating Provider, the insured is responsible for all fees in excess of the fee schedule. Co-Pays/Claim Payments are subject to change January 1st of each year. Insured plans are underwritten by Educators Health Plans Life, Accident & Health.
EMI Health: 5101 South Commerce Drive, Murray, Utah 84107 Toll Free: 800-662-5851 Web: emihealth.com