80%
Discount
In-Network
(Premier Network)
EMI COMPLETE CARE DHMO
Summary
of
Benefits
Orthodontics
Children (up to age 19)
Orthodontics
Discount (All Members)
No Coverage
Discount
No Coverage
Major
Crowns, bridge, dentures, inlays, periodontics, endodontics, oral surgery
Basic
Simple extractions and fillings
50%
No Coverage
100% after $25 copay
Preventive
Office visit, cleaning, oral exam and x-rays
No Coverage
No Out-of-Network Benefits
No Coverage
Waiting Periods
Preventive
None
Deductible (applies to Preventive, Basic, and Major
Individual
None
No Coverage
Maximums
Family Max
None
No Coverage
Major
None
Orthodontics
None
Basic
None
Network / Reimbursement schedule
Premier
Premier
$17.83
$35.62
$57.52
​​Monthly
Affinity
Rates
Subscriber
Subscriber + 1
Family​​
Annual Max
No Annual Max
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