Namara Marketplace

2017 QHP Landscape SHOP Market Dental

State Code

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Fips County Code

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County Name

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Metal Level

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Issuer Name

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Hios Issuer Id

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Plan Id (Standard Component)

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Plan Marketing Name

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Plan Type

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Rating Area

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Child Only Offering

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Source

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Customer Service Phone Number Local

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Customer Service Phone Number Toll Free

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Customer Service Phone Number Tty

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Network Url

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Plan Brochure Url

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Summary Of Benefits Url

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Drug Formulary Url

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Routine Dental Services - Adult (Coverage)

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Basic Dental Care - Adult (Coverage)

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Major Dental Care - Adult (Coverage)

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Orthodontia - Adult (Coverage)

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Dental Check-Up For Children (Coverage)

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Basic Dental Care - Child (Coverage)

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Major Dental Care - Child (Coverage)

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Orthodontia - Child (Coverage)

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Premium Rates

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Premium Child

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Premium Adult Individual Age 21

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Premium Adult Individual Age 27

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Premium Adult Individual Age 30

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Premium Adult Individual Age 40

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Premium Adult Individual Age 50

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Premium Adult Individual Age 60

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Premium Couple 21

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Premium Couple 30

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Premium Couple 40

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Premium Couple 50

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Premium Couple 60

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Couple+1 Child, Age 21

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Couple+1 Child, Age 30

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Couple+1 Child, Age 40

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Couple+1 Child, Age 50

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Couple+2 Children, Age 21

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Couple+2 Children, Age 30

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Couple+2 Children, Age 40

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Couple+2 Children, Age 50

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Couple+3 Or More Children, Age 21

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Couple+3 Or More Children, Age 30

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Couple+3 Or More Children, Age 40

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Couple+3 Or More Children, Age 50

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Individual+1 Child, Age 21

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Individual+1 Child, Age 30

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Individual+1 Child, Age 40

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Individual+1 Child, Age 50

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Individual+2 Children, Age 21

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Individual+2 Children, Age 30

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Individual+2 Children, Age 40

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Individual+2 Children, Age 50

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Individual+3 Or More Children, Age 21

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Individual+3 Or More Children, Age 30

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Individual+3 Or More Children, Age 40

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Individual+3 Or More Children, Age 50

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Standard On Exchange

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Dental Deductible - Individual - Standard

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Dental Deductible - Family - Standard

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Dental Deductible - Family (Per Person) - Standard

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Dental Maximum Out Of Pocket - Individual - Standard

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Dental Maximum Out Of Pocket - Family - Standard

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Dental Maximum Out Of Pocket - Family (Per Person) - Standard

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Routine Dental Services - Adult

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Basic Dental Care - Adult

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Major Dental Care - Adult

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Orthodontia - Adult

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Dental Check-Up For Children

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Basic Dental Care - Child

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Major Dental Care - Child

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Orthodontia - Child

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AK
02013
Aleutians East
Low
BEST Life and Health Insurance Company
74819
74819AK0010009
BESTDental Standard - L
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
49.04
52.39
52.39
52.39
52.39
52.39
98.08
104.78
104.78
104.78
104.78
136.25
142.95
142.95
142.95
174.42
181.12
181.12
181.12
212.59
219.29
219.29
219.29
87.21
90.56
90.56
90.56
125.38
128.73
128.73
128.73
163.55
166.9
166.9
166.9
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02013
Aleutians East
Low
BEST Life and Health Insurance Company
74819
74819AK0010011
BESTDental Choice - L
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
46.14
49.29
49.29
49.29
49.29
49.29
92.28
98.58
98.58
98.58
98.58
130.45
136.75
136.75
136.75
168.62
174.92
174.92
174.92
206.79
213.09
213.09
213.09
84.31
87.46
87.46
87.46
122.48
125.63
125.63
125.63
160.65
163.8
163.8
163.8
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02013
Aleutians East
Low
BEST Life and Health Insurance Company
74819
74819AK0010012
BESTDental Value
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
32.03
34.21
34.21
34.21
34.21
34.21
64.06
68.42
68.42
68.42
68.42
102.23
106.59
106.59
106.59
140.4
144.76
144.76
144.76
178.57
182.93
182.93
182.93
70.2
72.38
72.38
72.38
108.37
110.55
110.55
110.55
146.54
148.72
148.72
148.72
75
See Plan Brochure
75
350
700
350
No Charge
40% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02016
Aleutians West
High
Oregon Dental Service
21989
21989AK0090001
Delta Dental Premier Practical Plan 1000
Indemnity
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf
X
X
X
X
X
X
X
64
58
58
58
58
58
58
116
116
116
116
116
180
180
180
180
244
244
244
244
308
308
308
308
122
122
122
122
186
186
186
186
250
250
250
250
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02016
Aleutians West
High
Oregon Dental Service
21989
21989AK0090002
Delta Dental Premier Practical Plan 1500
Indemnity
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf
X
X
X
X
X
X
X
74
67
67
67
67
67
67
134
134
134
134
134
208
208
208
208
282
282
282
282
356
356
356
356
141
141
141
141
215
215
215
215
289
289
289
289
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02016
Aleutians West
Low
BEST Life and Health Insurance Company
74819
74819AK0010009
BESTDental Standard - L
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
49.04
52.39
52.39
52.39
52.39
52.39
98.08
104.78
104.78
104.78
104.78
136.25
142.95
142.95
142.95
174.42
181.12
181.12
181.12
212.59
219.29
219.29
219.29
87.21
90.56
90.56
90.56
125.38
128.73
128.73
128.73
163.55
166.9
166.9
166.9
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02016
Aleutians West
Low
BEST Life and Health Insurance Company
74819
74819AK0010011
BESTDental Choice - L
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
46.14
49.29
49.29
49.29
49.29
49.29
92.28
98.58
98.58
98.58
98.58
130.45
136.75
136.75
136.75
168.62
174.92
174.92
174.92
206.79
213.09
213.09
213.09
84.31
87.46
87.46
87.46
122.48
125.63
125.63
125.63
160.65
163.8
163.8
163.8
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02016
Aleutians West
Low
BEST Life and Health Insurance Company
74819
74819AK0010012
BESTDental Value
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
32.03
34.21
34.21
34.21
34.21
34.21
64.06
68.42
68.42
68.42
68.42
102.23
106.59
106.59
106.59
140.4
144.76
144.76
144.76
178.57
182.93
182.93
182.93
70.2
72.38
72.38
72.38
108.37
110.55
110.55
110.55
146.54
148.72
148.72
148.72
75
See Plan Brochure
75
350
700
350
No Charge
40% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02020
Anchorage
High
BEST Life and Health Insurance Company
74819
74819AK0010007
BESTDental Premium
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
49.3
54.94
58.7
58.7
58.7
58.7
58.7
109.88
117.4
117.4
117.4
117.4
159.18
166.7
166.7
166.7
208.48
216
216
216
257.78
265.3
265.3
265.3
104.24
108
108
108
153.54
157.3
157.3
157.3
202.84
206.6
206.6
206.6
50
See Plan Brochure
50
350
700
350
No Charge
10% Coinsurance after deductible
40% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02020
Anchorage
High
BEST Life and Health Insurance Company
74819
74819AK0010008
BESTDental Standard - H
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
49.3
49.04
52.39
52.39
52.39
52.39
52.39
98.08
104.78
104.78
104.78
104.78
147.38
154.08
154.08
154.08
196.68
203.38
203.38
203.38
245.98
252.68
252.68
252.68
98.34
101.69
101.69
101.69
147.64
150.99
150.99
150.99
196.94
200.29
200.29
200.29
50
See Plan Brochure
50
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02020
Anchorage
High
BEST Life and Health Insurance Company
74819
74819AK0010010
BESTDental Choice - H
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
49.3
46.14
49.29
49.29
49.29
49.29
49.29
92.28
98.58
98.58
98.58
98.58
141.58
147.88
147.88
147.88
190.88
197.18
197.18
197.18
240.18
246.48
246.48
246.48
95.44
98.59
98.59
98.59
144.74
147.89
147.89
147.89
194.04
197.19
197.19
197.19
50
See Plan Brochure
50
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02020
Anchorage
High
Oregon Dental Service
21989
21989AK0090001
Delta Dental Premier Practical Plan 1000
Indemnity
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf
X
X
X
X
X
X
X
64
58
58
58
58
58
58
116
116
116
116
116
180
180
180
180
244
244
244
244
308
308
308
308
122
122
122
122
186
186
186
186
250
250
250
250
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02020
Anchorage
High
Oregon Dental Service
21989
21989AK0090002
Delta Dental Premier Practical Plan 1500
Indemnity
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf
X
X
X
X
X
X
X
74
67
67
67
67
67
67
134
134
134
134
134
208
208
208
208
282
282
282
282
356
356
356
356
141
141
141
141
215
215
215
215
289
289
289
289
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02050
Bethel
High
Oregon Dental Service
21989
21989AK0090001
Delta Dental Premier Practical Plan 1000
Indemnity
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf
X
X
X
X
X
X
X
64
58
58
58
58
58
58
116
116
116
116
116
180
180
180
180
244
244
244
244
308
308
308
308
122
122
122
122
186
186
186
186
250
250
250
250
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02050
Bethel
High
Oregon Dental Service
21989
21989AK0090002
Delta Dental Premier Practical Plan 1500
Indemnity
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf
X
X
X
X
X
X
X
74
67
67
67
67
67
67
134
134
134
134
134
208
208
208
208
282
282
282
282
356
356
356
356
141
141
141
141
215
215
215
215
289
289
289
289
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02050
Bethel
Low
BEST Life and Health Insurance Company
74819
74819AK0010009
BESTDental Standard - L
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
49.04
52.39
52.39
52.39
52.39
52.39
98.08
104.78
104.78
104.78
104.78
136.25
142.95
142.95
142.95
174.42
181.12
181.12
181.12
212.59
219.29
219.29
219.29
87.21
90.56
90.56
90.56
125.38
128.73
128.73
128.73
163.55
166.9
166.9
166.9
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02050
Bethel
Low
BEST Life and Health Insurance Company
74819
74819AK0010011
BESTDental Choice - L
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
46.14
49.29
49.29
49.29
49.29
49.29
92.28
98.58
98.58
98.58
98.58
130.45
136.75
136.75
136.75
168.62
174.92
174.92
174.92
206.79
213.09
213.09
213.09
84.31
87.46
87.46
87.46
122.48
125.63
125.63
125.63
160.65
163.8
163.8
163.8
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02050
Bethel
Low
BEST Life and Health Insurance Company
74819
74819AK0010012
BESTDental Value
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
32.03
34.21
34.21
34.21
34.21
34.21
64.06
68.42
68.42
68.42
68.42
102.23
106.59
106.59
106.59
140.4
144.76
144.76
144.76
178.57
182.93
182.93
182.93
70.2
72.38
72.38
72.38
108.37
110.55
110.55
110.55
146.54
148.72
148.72
148.72
75
See Plan Brochure
75
350
700
350
No Charge
40% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02060
Bristol Bay
Low
BEST Life and Health Insurance Company
74819
74819AK0010009
BESTDental Standard - L
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
49.04
52.39
52.39
52.39
52.39
52.39
98.08
104.78
104.78
104.78
104.78
136.25
142.95
142.95
142.95
174.42
181.12
181.12
181.12
212.59
219.29
219.29
219.29
87.21
90.56
90.56
90.56
125.38
128.73
128.73
128.73
163.55
166.9
166.9
166.9
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02060
Bristol Bay
Low
BEST Life and Health Insurance Company
74819
74819AK0010011
BESTDental Choice - L
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
46.14
49.29
49.29
49.29
49.29
49.29
92.28
98.58
98.58
98.58
98.58
130.45
136.75
136.75
136.75
168.62
174.92
174.92
174.92
206.79
213.09
213.09
213.09
84.31
87.46
87.46
87.46
122.48
125.63
125.63
125.63
160.65
163.8
163.8
163.8
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02060
Bristol Bay
Low
BEST Life and Health Insurance Company
74819
74819AK0010012
BESTDental Value
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
32.03
34.21
34.21
34.21
34.21
34.21
64.06
68.42
68.42
68.42
68.42
102.23
106.59
106.59
106.59
140.4
144.76
144.76
144.76
178.57
182.93
182.93
182.93
70.2
72.38
72.38
72.38
108.37
110.55
110.55
110.55
146.54
148.72
148.72
148.72
75
See Plan Brochure
75
350
700
350
No Charge
40% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02068
Denali
High
Oregon Dental Service
21989
21989AK0090001
Delta Dental Premier Practical Plan 1000
Indemnity
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf
X
X
X
X
X
X
X
64
58
58
58
58
58
58
116
116
116
116
116
180
180
180
180
244
244
244
244
308
308
308
308
122
122
122
122
186
186
186
186
250
250
250
250
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02068
Denali
High
Oregon Dental Service
21989
21989AK0090002
Delta Dental Premier Practical Plan 1500
Indemnity
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf
X
X
X
X
X
X
X
74
67
67
67
67
67
67
134
134
134
134
134
208
208
208
208
282
282
282
282
356
356
356
356
141
141
141
141
215
215
215
215
289
289
289
289
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02090
Fairbanks North Star
High
Oregon Dental Service
21989
21989AK0090001
Delta Dental Premier Practical Plan 1000
Indemnity
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf
X
X
X
X
X
X
X
64
58
58
58
58
58
58
116
116
116
116
116
180
180
180
180
244
244
244
244
308
308
308
308
122
122
122
122
186
186
186
186
250
250
250
250
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02090
Fairbanks North Star
High
Oregon Dental Service
21989
21989AK0090002
Delta Dental Premier Practical Plan 1500
Indemnity
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf
X
X
X
X
X
X
X
74
67
67
67
67
67
67
134
134
134
134
134
208
208
208
208
282
282
282
282
356
356
356
356
141
141
141
141
215
215
215
215
289
289
289
289
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02090
Fairbanks North Star
Low
BEST Life and Health Insurance Company
74819
74819AK0010009
BESTDental Standard - L
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
49.04
52.39
52.39
52.39
52.39
52.39
98.08
104.78
104.78
104.78
104.78
136.25
142.95
142.95
142.95
174.42
181.12
181.12
181.12
212.59
219.29
219.29
219.29
87.21
90.56
90.56
90.56
125.38
128.73
128.73
128.73
163.55
166.9
166.9
166.9
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02090
Fairbanks North Star
Low
BEST Life and Health Insurance Company
74819
74819AK0010011
BESTDental Choice - L
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
46.14
49.29
49.29
49.29
49.29
49.29
92.28
98.58
98.58
98.58
98.58
130.45
136.75
136.75
136.75
168.62
174.92
174.92
174.92
206.79
213.09
213.09
213.09
84.31
87.46
87.46
87.46
122.48
125.63
125.63
125.63
160.65
163.8
163.8
163.8
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02090
Fairbanks North Star
Low
BEST Life and Health Insurance Company
74819
74819AK0010012
BESTDental Value
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
32.03
34.21
34.21
34.21
34.21
34.21
64.06
68.42
68.42
68.42
68.42
102.23
106.59
106.59
106.59
140.4
144.76
144.76
144.76
178.57
182.93
182.93
182.93
70.2
72.38
72.38
72.38
108.37
110.55
110.55
110.55
146.54
148.72
148.72
148.72
75
See Plan Brochure
75
350
700
350
No Charge
40% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02105
Hoonah Angoon
Low
BEST Life and Health Insurance Company
74819
74819AK0010009
BESTDental Standard - L
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
37.49
48.16
51.46
51.46
51.46
51.46
51.46
96.32
102.92
102.92
102.92
102.92
133.81
140.41
140.41
140.41
171.3
177.9
177.9
177.9
208.79
215.39
215.39
215.39
85.65
88.95
88.95
88.95
123.14
126.44
126.44
126.44
160.63
163.93
163.93
163.93
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02105
Hoonah Angoon
Low
BEST Life and Health Insurance Company
74819
74819AK0010011
BESTDental Choice - L
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
37.49
45.32
48.41
48.41
48.41
48.41
48.41
90.64
96.82
96.82
96.82
96.82
128.13
134.31
134.31
134.31
165.62
171.8
171.8
171.8
203.11
209.29
209.29
209.29
82.81
85.9
85.9
85.9
120.3
123.39
123.39
123.39
157.79
160.88
160.88
160.88
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02105
Hoonah Angoon
Low
BEST Life and Health Insurance Company
74819
74819AK0010012
BESTDental Value
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
37.49
31.46
33.6
33.6
33.6
33.6
33.6
62.92
67.2
67.2
67.2
67.2
100.41
104.69
104.69
104.69
137.9
142.18
142.18
142.18
175.39
179.67
179.67
179.67
68.95
71.09
71.09
71.09
106.44
108.58
108.58
108.58
143.93
146.07
146.07
146.07
75
See Plan Brochure
75
350
700
350
No Charge
40% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02110
Juneau
High
BEST Life and Health Insurance Company
74819
74819AK0010007
BESTDental Premium
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
48.42
53.96
57.65
57.65
57.65
57.65
57.65
107.92
115.3
115.3
115.3
115.3
156.34
163.72
163.72
163.72
204.76
212.14
212.14
212.14
253.18
260.56
260.56
260.56
102.38
106.07
106.07
106.07
150.8
154.49
154.49
154.49
199.22
202.91
202.91
202.91
50
See Plan Brochure
50
350
700
350
No Charge
10% Coinsurance after deductible
40% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02110
Juneau
High
BEST Life and Health Insurance Company
74819
74819AK0010008
BESTDental Standard - H
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
48.42
48.16
51.46
51.46
51.46
51.46
51.46
96.32
102.92
102.92
102.92
102.92
144.74
151.34
151.34
151.34
193.16
199.76
199.76
199.76
241.58
248.18
248.18
248.18
96.58
99.88
99.88
99.88
145
148.3
148.3
148.3
193.42
196.72
196.72
196.72
50
See Plan Brochure
50
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02110
Juneau
High
BEST Life and Health Insurance Company
74819
74819AK0010010
BESTDental Choice - H
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
48.42
45.32
48.41
48.41
48.41
48.41
48.41
90.64
96.82
96.82
96.82
96.82
139.06
145.24
145.24
145.24
187.48
193.66
193.66
193.66
235.9
242.08
242.08
242.08
93.74
96.83
96.83
96.83
142.16
145.25
145.25
145.25
190.58
193.67
193.67
193.67
50
See Plan Brochure
50
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02110
Juneau
High
Oregon Dental Service
21989
21989AK0090001
Delta Dental Premier Practical Plan 1000
Indemnity
Rating Area 3
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf
X
X
X
X
X
X
X
64
58
58
58
58
58
58
116
116
116
116
116
180
180
180
180
244
244
244
244
308
308
308
308
122
122
122
122
186
186
186
186
250
250
250
250
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02110
Juneau
High
Oregon Dental Service
21989
21989AK0090002
Delta Dental Premier Practical Plan 1500
Indemnity
Rating Area 3
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf
X
X
X
X
X
X
X
74
67
67
67
67
67
67
134
134
134
134
134
208
208
208
208
282
282
282
282
356
356
356
356
141
141
141
141
215
215
215
215
289
289
289
289
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02130
Ketchikan Gateway
High
BEST Life and Health Insurance Company
74819
74819AK0010007
BESTDental Premium
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
48.42
53.96
57.65
57.65
57.65
57.65
57.65
107.92
115.3
115.3
115.3
115.3
156.34
163.72
163.72
163.72
204.76
212.14
212.14
212.14
253.18
260.56
260.56
260.56
102.38
106.07
106.07
106.07
150.8
154.49
154.49
154.49
199.22
202.91
202.91
202.91
50
See Plan Brochure
50
350
700
350
No Charge
10% Coinsurance after deductible
40% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02130
Ketchikan Gateway
High
BEST Life and Health Insurance Company
74819
74819AK0010008
BESTDental Standard - H
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
48.42
48.16
51.46
51.46
51.46
51.46
51.46
96.32
102.92
102.92
102.92
102.92
144.74
151.34
151.34
151.34
193.16
199.76
199.76
199.76
241.58
248.18
248.18
248.18
96.58
99.88
99.88
99.88
145
148.3
148.3
148.3
193.42
196.72
196.72
196.72
50
See Plan Brochure
50
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02130
Ketchikan Gateway
High
BEST Life and Health Insurance Company
74819
74819AK0010010
BESTDental Choice - H
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
48.42
45.32
48.41
48.41
48.41
48.41
48.41
90.64
96.82
96.82
96.82
96.82
139.06
145.24
145.24
145.24
187.48
193.66
193.66
193.66
235.9
242.08
242.08
242.08
93.74
96.83
96.83
96.83
142.16
145.25
145.25
145.25
190.58
193.67
193.67
193.67
50
See Plan Brochure
50
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02164
Lake And Peninsula
High
Oregon Dental Service
21989
21989AK0090001
Delta Dental Premier Practical Plan 1000
Indemnity
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf
X
X
X
X
X
X
X
64
58
58
58
58
58
58
116
116
116
116
116
180
180
180
180
244
244
244
244
308
308
308
308
122
122
122
122
186
186
186
186
250
250
250
250
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02164
Lake And Peninsula
High
Oregon Dental Service
21989
21989AK0090002
Delta Dental Premier Practical Plan 1500
Indemnity
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf
X
X
X
X
X
X
X
74
67
67
67
67
67
67
134
134
134
134
134
208
208
208
208
282
282
282
282
356
356
356
356
141
141
141
141
215
215
215
215
289
289
289
289
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02180
Nome
Low
BEST Life and Health Insurance Company
74819
74819AK0010009
BESTDental Standard - L
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
49.04
52.39
52.39
52.39
52.39
52.39
98.08
104.78
104.78
104.78
104.78
136.25
142.95
142.95
142.95
174.42
181.12
181.12
181.12
212.59
219.29
219.29
219.29
87.21
90.56
90.56
90.56
125.38
128.73
128.73
128.73
163.55
166.9
166.9
166.9
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02180
Nome
Low
BEST Life and Health Insurance Company
74819
74819AK0010011
BESTDental Choice - L
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
46.14
49.29
49.29
49.29
49.29
49.29
92.28
98.58
98.58
98.58
98.58
130.45
136.75
136.75
136.75
168.62
174.92
174.92
174.92
206.79
213.09
213.09
213.09
84.31
87.46
87.46
87.46
122.48
125.63
125.63
125.63
160.65
163.8
163.8
163.8
75
See Plan Brochure
75
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02180
Nome
Low
BEST Life and Health Insurance Company
74819
74819AK0010012
BESTDental Value
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
38.17
32.03
34.21
34.21
34.21
34.21
34.21
64.06
68.42
68.42
68.42
68.42
102.23
106.59
106.59
106.59
140.4
144.76
144.76
144.76
178.57
182.93
182.93
182.93
70.2
72.38
72.38
72.38
108.37
110.55
110.55
110.55
146.54
148.72
148.72
148.72
75
See Plan Brochure
75
350
700
350
No Charge
40% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02188
Northwest Arctic
High
BEST Life and Health Insurance Company
74819
74819AK0010007
BESTDental Premium
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
49.3
54.94
58.7
58.7
58.7
58.7
58.7
109.88
117.4
117.4
117.4
117.4
159.18
166.7
166.7
166.7
208.48
216
216
216
257.78
265.3
265.3
265.3
104.24
108
108
108
153.54
157.3
157.3
157.3
202.84
206.6
206.6
206.6
50
See Plan Brochure
50
350
700
350
No Charge
10% Coinsurance after deductible
40% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02188
Northwest Arctic
High
BEST Life and Health Insurance Company
74819
74819AK0010008
BESTDental Standard - H
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
49.3
49.04
52.39
52.39
52.39
52.39
52.39
98.08
104.78
104.78
104.78
104.78
147.38
154.08
154.08
154.08
196.68
203.38
203.38
203.38
245.98
252.68
252.68
252.68
98.34
101.69
101.69
101.69
147.64
150.99
150.99
150.99
196.94
200.29
200.29
200.29
50
See Plan Brochure
50
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02188
Northwest Arctic
High
BEST Life and Health Insurance Company
74819
74819AK0010010
BESTDental Choice - H
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
X
X
X
X
X
X
X
49.3
46.14
49.29
49.29
49.29
49.29
49.29
92.28
98.58
98.58
98.58
98.58
141.58
147.88
147.88
147.88
190.88
197.18
197.18
197.18
240.18
246.48
246.48
246.48
95.44
98.59
98.59
98.59
144.74
147.89
147.89
147.89
194.04
197.19
197.19
197.19
50
See Plan Brochure
50
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
50%
AK
02220
Sitka
High
Oregon Dental Service
21989
21989AK0090001
Delta Dental Premier Practical Plan 1000
Indemnity
Rating Area 3
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf
X
X
X
X
X
X
X
64
58
58
58
58
58
58
116
116
116
116
116
180
180
180
180
244
244
244
244
308
308
308
308
122
122
122
122
186
186
186
186
250
250
250
250
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02220
Sitka
High
Oregon Dental Service
21989
21989AK0090002
Delta Dental Premier Practical Plan 1500
Indemnity
Rating Area 3
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1500_SG_2017_AK.pdf
X
X
X
X
X
X
X
74
67
67
67
67
67
67
134
134
134
134
134
208
208
208
208
282
282
282
282
356
356
356
356
141
141
141
141
215
215
215
215
289
289
289
289
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
AK
02240
Southeast Fairbanks
High
Oregon Dental Service
21989
21989AK0090001
Delta Dental Premier Practical Plan 1000
Indemnity
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-235-8014
1-844-235-8014
1-844-235-8014
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_DeltaDentalPremierPracticalPlan1000_SG_2017_AK.pdf
X
X
X
X
X
X
X
64
58
58
58
58
58
58
116
116
116
116
116
180
180
180
180
244
244
244
244
308
308
308
308
122
122
122
122
186
186
186
186
250
250
250
250
50
$150
50
350
700
350
20%
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible

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