Insured Dental Plan (People First Plan Code: 4074)

The Freedom Advance Insured Plan provides you with a choice of any dentist or specialist you choose. By seeing a Dental Health Alliance, L.L.C.® (DHA®) dentist, you will receive discounts off their usual fees by approximately 30% which can save you money. To locate a participating dentist in your area, visit PPO Dental Provider to complete the search. Claim forms must be filed, and certain limitations and exclusions apply. Coverage includes dental and vision benefits for one low cost, through payroll deduction. This plan is underwritten by Union Security Insurance Company.

This page includes a brief summary of the Freedom Advance insured plan benefits. A complete description of insured benefits, including limitations and exclusions, will be provided in the Certificate of Insurance.

Payroll Deduction Bi-weekly (24) Monthly
Employee $20.74 $41.48
Employee/Spouse $39.82 $79.63
Employee/Child(ren) $46.92 $93.84
Employee/Family $62.07 $124.14
FREEDOM ADVANCE SM
Benefit Maximum (Per Individual Benefit Year) $1,250
In Network
$1,250
Out of Network
Deductible (Per Individual Benefit Year) $50 (Applies to Type II and III Services Only)
Coinsurance Percentage (Per Individual Benefit Year)
  Type I Type II Type III
During the 1st year 100% 80% 25%
During the 2nd year 100% 80% 50%
During the 3rd year & thereafter 100% 80% 50%
Type IV Dental Services 50%
Lifetime Orthodontia Maximum $1,000

New Lifetime of Smiles® program features:

  • 4 periodontal cleanings per year
  • White fillings on back teeth
  • Brush biopsies for early cancer detection
  • Testing for genetic gum disease
  • Coverage for antimicrobial agents
  • Discounts on dental healthcare products

Type I Preventive Dental Services, Including:

  • Routine Oral Exams
  • Routine Dental Cleanings
  • Fluoride Treatment (children under 14)
  • Sealants (children under 16)
  • Space Maintainers (children under 16)
  • Harmful Habit Appliance (children under 16)
  • Bitewing X-Rays

Type II Basic Dental Services, Including:

  • X-Rays:
    • Complete Series
    • Panoramic
    • Other X-Rays (See Certificate of Insurance)
  • New Fillings: Replacement Fillings
  • Simple Extractions, Removal of Exposed Roots, Incision and Drainage
  • Certain Lab Tests, Pain Treatment, Therapeutic Drug Injections

Type III Major Dental Services, Including:

  • Endodontics
  • Endodontic Retreatment
  • Complex Oral Surgery
  • Minor Gum Disease Treatment
    • Provisional Splinting, Occlusal Adjustments
    • Scaling and Root Planing
    • Periodontal Maintenance
  • Major Gum Disease Treatment
    • Gingivectomy, Osseous Surgery, Other Major Periodontic Procedures
  • Initial Placement, Replacement and Maintenance of Inlays, Onlays, Crowns, Fixed Partial Dentures (Bridges), and Partial and Complete Dentures

Type IV Orthodontic Dental Services

(Only for dependent children under age 19)
  • Limited Orthodontic Treatment
  • Interceptive Orthodontic Treatment
  • Comprehensive Orthodontic Treatment
  • Minor Treatment to control harmful habits
  • 12 Month Waiting Period

This page includes a brief summary of the insured plan benefits. A complete description of insured benefits, including limitations and exclusions, will be provided in the Certificate of Insurance.

The percentage paid is based on the allowable charges which are current charges for the area where the services are performed.