Namara Marketplace

2016 QHP Landscape HI Individual Market Dental

State Code

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County Name

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Metal Level

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Issuer Name

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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 1

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Basic Dental Care Adult 1

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Major Dental Care Adult 1

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Orthodontia Adult 1

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Dental Check-Up For Children

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Basic Dental Care Child 1

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Major Dental Care Child 1

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Orthodontia Child 1

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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 Checkup 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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HI
Hawaii
Low
Hawaii Dental Service Corporation
46082HI0020001
HDS Individual Dental Plan for Children
PPO
Rating Area 1
Allows Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Individual_Dental_Plan_for_Children_0715.pdf
X
X
X
X
31.2
$50
See Plan Brochure
$50
350
700
350
Not Covered
Not Covered
Not Covered
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Honolulu
Low
Hawaii Dental Service Corporation
46082HI0020001
HDS Individual Dental Plan for Children
PPO
Rating Area 1
Allows Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Individual_Dental_Plan_for_Children_0715.pdf
X
X
X
X
31.2
$50
See Plan Brochure
$50
350
700
350
Not Covered
Not Covered
Not Covered
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Kauai
Low
Hawaii Dental Service Corporation
46082HI0020001
HDS Individual Dental Plan for Children
PPO
Rating Area 1
Allows Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Individual_Dental_Plan_for_Children_0715.pdf
X
X
X
X
31.2
$50
See Plan Brochure
$50
350
700
350
Not Covered
Not Covered
Not Covered
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Maui
Low
Hawaii Dental Service Corporation
46082HI0020001
HDS Individual Dental Plan for Children
PPO
Rating Area 1
Allows Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Individual_Dental_Plan_for_Children_0715.pdf
X
X
X
X
31.2
$50
See Plan Brochure
$50
350
700
350
Not Covered
Not Covered
Not Covered
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Hawaii
High
BEST Life and Health Insurance Company
10046HI0020003
BESTOne Advantage Gold
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
56.12
62.07
66.31
66.31
66.31
66.31
66.31
124.14
132.62
132.62
132.62
132.62
180.26
188.74
188.74
188.74
236.38
244.86
244.86
244.86
292.5
300.98
300.98
300.98
118.19
122.43
122.43
122.43
174.31
178.55
178.55
178.55
230.43
234.67
234.67
234.67
$75
See Plan Brochure
$75
350
700
350
No Charge
10% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Hawaii
High
BEST Life and Health Insurance Company
10046HI0020004
BESTOne Plus Gold
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
56.12
51.59
55.12
55.12
55.12
55.12
55.12
103.18
110.24
110.24
110.24
110.24
159.3
166.36
166.36
166.36
215.42
222.48
222.48
222.48
271.54
278.6
278.6
278.6
107.71
111.24
111.24
111.24
163.83
167.36
167.36
167.36
219.95
223.48
223.48
223.48
$75
See Plan Brochure
$75
350
700
350
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Hawaii
High
Hawaii Medical Service Association
18350HI0920001
HMSA Individual Dental PPP High
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
X
39.13
32.91
32.91
32.91
32.91
32.91
32.91
65.82
65.82
65.82
65.82
65.82
104.95
104.95
104.95
104.95
144.08
144.08
144.08
144.08
183.21
183.21
183.21
183.21
72.04
72.04
72.04
72.04
111.17
111.17
111.17
111.17
150.3
150.3
150.3
150.3
$0
$0
$0
350
700
350
No Charge
30%
50%
Not Covered
No Charge
30%
50%
0.5
HI
Hawaii
Low
Hawaii Medical Service Association
18350HI0930001
HMSA Individual Dental HMO Basic
HMO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
X
21.39
20.35
20.35
20.35
20.35
20.35
20.35
40.7
40.7
40.7
40.7
40.7
62.09
62.09
62.09
62.09
83.48
83.48
83.48
83.48
104.87
104.87
104.87
104.87
41.74
41.74
41.74
41.74
63.13
63.13
63.13
63.13
84.52
84.52
84.52
84.52
Not Applicable
Not Applicable
Not Applicable
350
700
350
$10
$40
$250
Not Covered
$10
$40
$250
0.5
HI
Honolulu
High
BEST Life and Health Insurance Company
10046HI0020003
BESTOne Advantage Gold
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
56.12
62.07
66.31
66.31
66.31
66.31
66.31
124.14
132.62
132.62
132.62
132.62
180.26
188.74
188.74
188.74
236.38
244.86
244.86
244.86
292.5
300.98
300.98
300.98
118.19
122.43
122.43
122.43
174.31
178.55
178.55
178.55
230.43
234.67
234.67
234.67
$75
See Plan Brochure
$75
350
700
350
No Charge
10% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Honolulu
High
BEST Life and Health Insurance Company
10046HI0020004
BESTOne Plus Gold
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
56.12
51.59
55.12
55.12
55.12
55.12
55.12
103.18
110.24
110.24
110.24
110.24
159.3
166.36
166.36
166.36
215.42
222.48
222.48
222.48
271.54
278.6
278.6
278.6
107.71
111.24
111.24
111.24
163.83
167.36
167.36
167.36
219.95
223.48
223.48
223.48
$75
See Plan Brochure
$75
350
700
350
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Honolulu
High
Hawaii Medical Service Association
18350HI0920001
HMSA Individual Dental PPP High
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
X
39.13
32.91
32.91
32.91
32.91
32.91
32.91
65.82
65.82
65.82
65.82
65.82
104.95
104.95
104.95
104.95
144.08
144.08
144.08
144.08
183.21
183.21
183.21
183.21
72.04
72.04
72.04
72.04
111.17
111.17
111.17
111.17
150.3
150.3
150.3
150.3
$0
$0
$0
350
700
350
No Charge
30%
50%
Not Covered
No Charge
30%
50%
0.5
HI
Honolulu
Low
Hawaii Medical Service Association
18350HI0930001
HMSA Individual Dental HMO Basic
HMO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
X
21.39
20.35
20.35
20.35
20.35
20.35
20.35
40.7
40.7
40.7
40.7
40.7
62.09
62.09
62.09
62.09
83.48
83.48
83.48
83.48
104.87
104.87
104.87
104.87
41.74
41.74
41.74
41.74
63.13
63.13
63.13
63.13
84.52
84.52
84.52
84.52
Not Applicable
Not Applicable
Not Applicable
350
700
350
$10
$40
$250
Not Covered
$10
$40
$250
0.5
HI
Kauai
High
BEST Life and Health Insurance Company
10046HI0020003
BESTOne Advantage Gold
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
56.12
62.07
66.31
66.31
66.31
66.31
66.31
124.14
132.62
132.62
132.62
132.62
180.26
188.74
188.74
188.74
236.38
244.86
244.86
244.86
292.5
300.98
300.98
300.98
118.19
122.43
122.43
122.43
174.31
178.55
178.55
178.55
230.43
234.67
234.67
234.67
$75
See Plan Brochure
$75
350
700
350
No Charge
10% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Kauai
High
BEST Life and Health Insurance Company
10046HI0020004
BESTOne Plus Gold
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
56.12
51.59
55.12
55.12
55.12
55.12
55.12
103.18
110.24
110.24
110.24
110.24
159.3
166.36
166.36
166.36
215.42
222.48
222.48
222.48
271.54
278.6
278.6
278.6
107.71
111.24
111.24
111.24
163.83
167.36
167.36
167.36
219.95
223.48
223.48
223.48
$75
See Plan Brochure
$75
350
700
350
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Kauai
High
Hawaii Medical Service Association
18350HI0920001
HMSA Individual Dental PPP High
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
X
39.13
32.91
32.91
32.91
32.91
32.91
32.91
65.82
65.82
65.82
65.82
65.82
104.95
104.95
104.95
104.95
144.08
144.08
144.08
144.08
183.21
183.21
183.21
183.21
72.04
72.04
72.04
72.04
111.17
111.17
111.17
111.17
150.3
150.3
150.3
150.3
$0
$0
$0
350
700
350
No Charge
30%
50%
Not Covered
No Charge
30%
50%
0.5
HI
Kauai
Low
Hawaii Medical Service Association
18350HI0930001
HMSA Individual Dental HMO Basic
HMO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
X
21.39
20.35
20.35
20.35
20.35
20.35
20.35
40.7
40.7
40.7
40.7
40.7
62.09
62.09
62.09
62.09
83.48
83.48
83.48
83.48
104.87
104.87
104.87
104.87
41.74
41.74
41.74
41.74
63.13
63.13
63.13
63.13
84.52
84.52
84.52
84.52
Not Applicable
Not Applicable
Not Applicable
350
700
350
$10
$40
$250
Not Covered
$10
$40
$250
0.5
HI
Maui
High
BEST Life and Health Insurance Company
10046HI0020003
BESTOne Advantage Gold
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
56.12
62.07
66.31
66.31
66.31
66.31
66.31
124.14
132.62
132.62
132.62
132.62
180.26
188.74
188.74
188.74
236.38
244.86
244.86
244.86
292.5
300.98
300.98
300.98
118.19
122.43
122.43
122.43
174.31
178.55
178.55
178.55
230.43
234.67
234.67
234.67
$75
See Plan Brochure
$75
350
700
350
No Charge
10% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Maui
High
BEST Life and Health Insurance Company
10046HI0020004
BESTOne Plus Gold
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
56.12
51.59
55.12
55.12
55.12
55.12
55.12
103.18
110.24
110.24
110.24
110.24
159.3
166.36
166.36
166.36
215.42
222.48
222.48
222.48
271.54
278.6
278.6
278.6
107.71
111.24
111.24
111.24
163.83
167.36
167.36
167.36
219.95
223.48
223.48
223.48
$75
See Plan Brochure
$75
350
700
350
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Maui
High
Hawaii Medical Service Association
18350HI0920001
HMSA Individual Dental PPP High
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
X
39.13
32.91
32.91
32.91
32.91
32.91
32.91
65.82
65.82
65.82
65.82
65.82
104.95
104.95
104.95
104.95
144.08
144.08
144.08
144.08
183.21
183.21
183.21
183.21
72.04
72.04
72.04
72.04
111.17
111.17
111.17
111.17
150.3
150.3
150.3
150.3
$0
$0
$0
350
700
350
No Charge
30%
50%
Not Covered
No Charge
30%
50%
0.5
HI
Maui
Low
Hawaii Medical Service Association
18350HI0930001
HMSA Individual Dental HMO Basic
HMO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
X
21.39
20.35
20.35
20.35
20.35
20.35
20.35
40.7
40.7
40.7
40.7
40.7
62.09
62.09
62.09
62.09
83.48
83.48
83.48
83.48
104.87
104.87
104.87
104.87
41.74
41.74
41.74
41.74
63.13
63.13
63.13
63.13
84.52
84.52
84.52
84.52
Not Applicable
Not Applicable
Not Applicable
350
700
350
$10
$40
$250
Not Covered
$10
$40
$250
0.5
HI
Hawaii
High
Hawaii Medical Service Association
18350HI0920005
HMSA Individual Dental PPP Pediatric Essential
PPO
Rating Area 1
Allows Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
39.37
$0
$0
$0
350
700
350
Not Covered
Not Covered
Not Covered
Not Covered
No Charge
30%
50%
0.5
HI
Hawaii
Low
BEST Life and Health Insurance Company
10046HI0020005
BESTOne Plus Silver
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
46.59
49.09
52.45
52.45
52.45
52.45
52.45
98.18
104.9
104.9
104.9
104.9
144.77
151.49
151.49
151.49
191.36
198.08
198.08
198.08
237.95
244.67
244.67
244.67
95.68
99.04
99.04
99.04
142.27
145.63
145.63
145.63
188.86
192.22
192.22
192.22
$75
See Plan Brochure
$75
350
700
350
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge
40% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Hawaii
Low
BEST Life and Health Insurance Company
10046HI0020006
BESTOne Basic Silver
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
46.59
35.3
37.71
37.71
37.71
37.71
37.71
70.6
75.42
75.42
75.42
75.42
117.19
122.01
122.01
122.01
163.78
168.6
168.6
168.6
210.37
215.19
215.19
215.19
81.89
84.3
84.3
84.3
128.48
130.89
130.89
130.89
175.07
177.48
177.48
177.48
$75
See Plan Brochure
$75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
40% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Hawaii
Low
Hawaii Dental Service Corporation
46082HI0020003
HDS Preferred Dental Plan
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Preferred_Dental_Plan_0715.pdf
X
X
X
X
X
X
X
35.3
28.7
31.2
32.7
34.4
38.1
44.2
57.4
65.4
68.8
76.2
88.4
92.7
100.7
104.1
111.5
128
136
139.4
146.8
163.3
171.3
174.7
182.1
64
68
69.7
73.4
99.3
103.3
105
108.7
134.6
138.6
140.3
144
$50
See Plan Brochure
$50
350
700
350
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Hawaii
Low
Hawaii Dental Service Corporation
46082HI0020004
HDS Classic Dental Plan
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Classic_Dental_Plan_0715.pdf
X
X
X
X
X
X
X
31.2
22.8
24.8
26.1
27.5
30.4
35.2
45.6
52.2
55
60.8
70.4
76.8
83.4
86.2
92
108
114.6
117.4
123.2
139.2
145.8
148.6
154.4
54
57.3
58.7
61.6
85.2
88.5
89.9
92.8
116.4
119.7
121.1
124
$50
See Plan Brochure
$50
350
700
350
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Hawaii
Low
Hawaii Medical Service Association
18350HI0920002
HMSA Individual Dental PPP Basic
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
32.85
15.89
15.89
15.89
15.89
15.89
15.89
31.78
31.78
31.78
31.78
31.78
64.63
64.63
64.63
64.63
97.48
97.48
97.48
97.48
130.33
130.33
130.33
130.33
48.74
48.74
48.74
48.74
81.59
81.59
81.59
81.59
114.44
114.44
114.44
114.44
$25
See Plan Brochure
$25
350
700
350
10% Coinsurance after deductible
40% Coinsurance after deductible
Not Covered
Not Covered
10% Coinsurance after deductible
40% Coinsurance after deductible
60% Coinsurance after deductible
0.6
HI
Honolulu
High
Hawaii Medical Service Association
18350HI0920005
HMSA Individual Dental PPP Pediatric Essential
PPO
Rating Area 1
Allows Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
39.37
$0
$0
$0
350
700
350
Not Covered
Not Covered
Not Covered
Not Covered
No Charge
30%
50%
0.5
HI
Honolulu
Low
BEST Life and Health Insurance Company
10046HI0020005
BESTOne Plus Silver
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
46.59
49.09
52.45
52.45
52.45
52.45
52.45
98.18
104.9
104.9
104.9
104.9
144.77
151.49
151.49
151.49
191.36
198.08
198.08
198.08
237.95
244.67
244.67
244.67
95.68
99.04
99.04
99.04
142.27
145.63
145.63
145.63
188.86
192.22
192.22
192.22
$75
See Plan Brochure
$75
350
700
350
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge
40% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Honolulu
Low
BEST Life and Health Insurance Company
10046HI0020006
BESTOne Basic Silver
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
46.59
35.3
37.71
37.71
37.71
37.71
37.71
70.6
75.42
75.42
75.42
75.42
117.19
122.01
122.01
122.01
163.78
168.6
168.6
168.6
210.37
215.19
215.19
215.19
81.89
84.3
84.3
84.3
128.48
130.89
130.89
130.89
175.07
177.48
177.48
177.48
$75
See Plan Brochure
$75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
40% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Honolulu
Low
Dentegra Insurance Company
50397HI0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
http://www.dentegra.com/hcx/hi/50397hi0010006-16
X
X
X
X
X
X
25.63
27.27
27.27
27.27
27.27
27.27
27.27
54.54
54.54
54.54
54.54
54.54
80.17
80.17
80.17
80.17
105.8
105.8
105.8
105.8
131.43
131.43
131.43
131.43
52.9
52.9
52.9
52.9
78.53
78.53
78.53
78.53
104.16
104.16
104.16
104.16
$75
See Plan Brochure
Not Applicable
350
700
350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Honolulu
Low
Hawaii Dental Service Corporation
46082HI0020003
HDS Preferred Dental Plan
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Preferred_Dental_Plan_0715.pdf
X
X
X
X
X
X
X
35.3
28.7
31.2
32.7
34.4
38.1
44.2
57.4
65.4
68.8
76.2
88.4
92.7
100.7
104.1
111.5
128
136
139.4
146.8
163.3
171.3
174.7
182.1
64
68
69.7
73.4
99.3
103.3
105
108.7
134.6
138.6
140.3
144
$50
See Plan Brochure
$50
350
700
350
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Honolulu
Low
Hawaii Dental Service Corporation
46082HI0020004
HDS Classic Dental Plan
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Classic_Dental_Plan_0715.pdf
X
X
X
X
X
X
X
31.2
22.8
24.8
26.1
27.5
30.4
35.2
45.6
52.2
55
60.8
70.4
76.8
83.4
86.2
92
108
114.6
117.4
123.2
139.2
145.8
148.6
154.4
54
57.3
58.7
61.6
85.2
88.5
89.9
92.8
116.4
119.7
121.1
124
$50
See Plan Brochure
$50
350
700
350
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Honolulu
Low
Hawaii Medical Service Association
18350HI0920002
HMSA Individual Dental PPP Basic
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
32.85
15.89
15.89
15.89
15.89
15.89
15.89
31.78
31.78
31.78
31.78
31.78
64.63
64.63
64.63
64.63
97.48
97.48
97.48
97.48
130.33
130.33
130.33
130.33
48.74
48.74
48.74
48.74
81.59
81.59
81.59
81.59
114.44
114.44
114.44
114.44
$25
See Plan Brochure
$25
350
700
350
10% Coinsurance after deductible
40% Coinsurance after deductible
Not Covered
Not Covered
10% Coinsurance after deductible
40% Coinsurance after deductible
60% Coinsurance after deductible
0.6
HI
Kauai
High
Hawaii Medical Service Association
18350HI0920005
HMSA Individual Dental PPP Pediatric Essential
PPO
Rating Area 1
Allows Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
39.37
$0
$0
$0
350
700
350
Not Covered
Not Covered
Not Covered
Not Covered
No Charge
30%
50%
0.5
HI
Kauai
Low
BEST Life and Health Insurance Company
10046HI0020005
BESTOne Plus Silver
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
46.59
49.09
52.45
52.45
52.45
52.45
52.45
98.18
104.9
104.9
104.9
104.9
144.77
151.49
151.49
151.49
191.36
198.08
198.08
198.08
237.95
244.67
244.67
244.67
95.68
99.04
99.04
99.04
142.27
145.63
145.63
145.63
188.86
192.22
192.22
192.22
$75
See Plan Brochure
$75
350
700
350
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge
40% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Kauai
Low
BEST Life and Health Insurance Company
10046HI0020006
BESTOne Basic Silver
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
46.59
35.3
37.71
37.71
37.71
37.71
37.71
70.6
75.42
75.42
75.42
75.42
117.19
122.01
122.01
122.01
163.78
168.6
168.6
168.6
210.37
215.19
215.19
215.19
81.89
84.3
84.3
84.3
128.48
130.89
130.89
130.89
175.07
177.48
177.48
177.48
$75
See Plan Brochure
$75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
40% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Kauai
Low
Hawaii Dental Service Corporation
46082HI0020003
HDS Preferred Dental Plan
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Preferred_Dental_Plan_0715.pdf
X
X
X
X
X
X
X
35.3
28.7
31.2
32.7
34.4
38.1
44.2
57.4
65.4
68.8
76.2
88.4
92.7
100.7
104.1
111.5
128
136
139.4
146.8
163.3
171.3
174.7
182.1
64
68
69.7
73.4
99.3
103.3
105
108.7
134.6
138.6
140.3
144
$50
See Plan Brochure
$50
350
700
350
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Kauai
Low
Hawaii Dental Service Corporation
46082HI0020004
HDS Classic Dental Plan
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Classic_Dental_Plan_0715.pdf
X
X
X
X
X
X
X
31.2
22.8
24.8
26.1
27.5
30.4
35.2
45.6
52.2
55
60.8
70.4
76.8
83.4
86.2
92
108
114.6
117.4
123.2
139.2
145.8
148.6
154.4
54
57.3
58.7
61.6
85.2
88.5
89.9
92.8
116.4
119.7
121.1
124
$50
See Plan Brochure
$50
350
700
350
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Kauai
Low
Hawaii Medical Service Association
18350HI0920002
HMSA Individual Dental PPP Basic
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
32.85
15.89
15.89
15.89
15.89
15.89
15.89
31.78
31.78
31.78
31.78
31.78
64.63
64.63
64.63
64.63
97.48
97.48
97.48
97.48
130.33
130.33
130.33
130.33
48.74
48.74
48.74
48.74
81.59
81.59
81.59
81.59
114.44
114.44
114.44
114.44
$25
See Plan Brochure
$25
350
700
350
10% Coinsurance after deductible
40% Coinsurance after deductible
Not Covered
Not Covered
10% Coinsurance after deductible
40% Coinsurance after deductible
60% Coinsurance after deductible
0.6
HI
Maui
High
Hawaii Medical Service Association
18350HI0920005
HMSA Individual Dental PPP Pediatric Essential
PPO
Rating Area 1
Allows Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
39.37
$0
$0
$0
350
700
350
Not Covered
Not Covered
Not Covered
Not Covered
No Charge
30%
50%
0.5
HI
Maui
Low
BEST Life and Health Insurance Company
10046HI0020005
BESTOne Plus Silver
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
46.59
49.09
52.45
52.45
52.45
52.45
52.45
98.18
104.9
104.9
104.9
104.9
144.77
151.49
151.49
151.49
191.36
198.08
198.08
198.08
237.95
244.67
244.67
244.67
95.68
99.04
99.04
99.04
142.27
145.63
145.63
145.63
188.86
192.22
192.22
192.22
$75
See Plan Brochure
$75
350
700
350
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge
40% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Maui
Low
BEST Life and Health Insurance Company
10046HI0020006
BESTOne Basic Silver
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/exchange/provider.html
https://www.bestlife.com/HI/2015/HI_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
46.59
35.3
37.71
37.71
37.71
37.71
37.71
70.6
75.42
75.42
75.42
75.42
117.19
122.01
122.01
122.01
163.78
168.6
168.6
168.6
210.37
215.19
215.19
215.19
81.89
84.3
84.3
84.3
128.48
130.89
130.89
130.89
175.07
177.48
177.48
177.48
$75
See Plan Brochure
$75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
40% Coinsurance after deductible
50% Coinsurance after deductible
0.5
HI
Maui
Low
Hawaii Dental Service Corporation
46082HI0020003
HDS Preferred Dental Plan
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Preferred_Dental_Plan_0715.pdf
X
X
X
X
X
X
X
35.3
28.7
31.2
32.7
34.4
38.1
44.2
57.4
65.4
68.8
76.2
88.4
92.7
100.7
104.1
111.5
128
136
139.4
146.8
163.3
171.3
174.7
182.1
64
68
69.7
73.4
99.3
103.3
105
108.7
134.6
138.6
140.3
144
$50
See Plan Brochure
$50
350
700
350
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Maui
Low
Hawaii Dental Service Corporation
46082HI0020004
HDS Classic Dental Plan
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-521-1431
https://www.hawaiidentalservice.com/ddpahi/HtmlPage.jsp?DView=providerSearch
http://www.hawaiidentalservice.com/ddpahi/Form_HDS_Classic_Dental_Plan_0715.pdf
X
X
X
X
X
X
X
31.2
22.8
24.8
26.1
27.5
30.4
35.2
45.6
52.2
55
60.8
70.4
76.8
83.4
86.2
92
108
114.6
117.4
123.2
139.2
145.8
148.6
154.4
54
57.3
58.7
61.6
85.2
88.5
89.9
92.8
116.4
119.7
121.1
124
$50
See Plan Brochure
$50
350
700
350
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
70% Coinsurance after deductible
70% Coinsurance after deductible
0.5
HI
Maui
Low
Hawaii Medical Service Association
18350HI0920002
HMSA Individual Dental PPP Basic
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-808-948-5555
1-800-620-4672
http://www.hmsa.com/search/providers
X
X
X
X
X
X
32.85
15.89
15.89
15.89
15.89
15.89
15.89
31.78
31.78
31.78
31.78
31.78
64.63
64.63
64.63
64.63
97.48
97.48
97.48
97.48
130.33
130.33
130.33
130.33
48.74
48.74
48.74
48.74
81.59
81.59
81.59
81.59
114.44
114.44
114.44
114.44
$25
See Plan Brochure
$25
350
700
350
10% Coinsurance after deductible
40% Coinsurance after deductible
Not Covered
Not Covered
10% Coinsurance after deductible
40% Coinsurance after deductible
60% Coinsurance after deductible
0.6

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