ORTHO WAITING PERIOD
18 MONTH WAITING PERIOD
Orthodontics
Children (up to age 19)
50%
20%
Orthodontics
Discount (All Members)
Discount
NO COVERAGE
EMI PREMIER PPO (HIGH) PLAN
Major
Crowns, bridge, dentures, inlays, periodontics, endodontics, oral surgery and Implants (1)
50%
40% UP TO
Basic
Simple extractions and fillings
80%
40% UP TO
Preventive
Office visit, cleaning, oral exam and x-rays
In-Network
(Premier Network)
100%
Out-of-Network
80% UP TO
Summary
of
Benefits
Waiting Periods
Preventive
None
$1,000
$1,000
Deductible (applies to Preventive, Basic, and Major
Individual
$50
$50
Maximums
Annual Max per Person
Major Annual Max
Family Max
$750
Ortho Lifetime Max
(Medically / Non Medically Necessary)
$150
$150
Network / Reimbursement schedule
Premier
Premier
$48.00
$90.00
$124.00
$174.00
​​
Monthly
Affinity
Rates
Subscriber
Subscriber + 1
Subscriber + 2
Subscriber + 3​
Major
15 Month Waiting Period
Orthodontics
24 Month Waiting Period
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