Namara Marketplace

QHP Landscape Individual Market Dental

State

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County

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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

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Major Dental Care - Adult

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Orthodontia Adult 1

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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 1

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Premium Scenarios

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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 Plan Cost Sharing

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Dental Deductible -Individual

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Dental Deductible - Family

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Maximum Out Of Pocket -Individual

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Maximum Out Of Pocket - Family

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Routine Dental Services Adult

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Basic Dental Adult

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Major Dental Adult

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Orthodontia Adult

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Dental Check-Up Child

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Basic Dental Child

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Major Dental Child

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Orthodontia Child

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AK
ALEUTIANS EAST
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.84
75.84
75.84
75.84
75.84
75.84
75.84
151.66
151.66
151.66
151.66
151.66
212.56
212.56
212.56
212.56
273.44
273.44
273.44
273.44
358.68
358.68
358.68
358.68
136.72
136.72
136.72
136.72
197.61
197.61
197.61
197.61
282.85
282.85
282.85
282.85
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
ALEUTIANS EAST
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
58.02
58.02
58.02
58.02
58.02
58.02
58.02
116.04
116.04
116.04
116.04
116.04
173.59
173.59
173.59
173.59
231.14
231.14
231.14
231.14
311.7
311.7
311.7
311.7
115.57
115.57
115.57
115.57
173.12
173.12
173.12
173.12
253.69
253.69
253.69
253.69
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
ALEUTIANS EAST
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
ALEUTIANS WEST
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.84
75.84
75.84
75.84
75.84
75.84
75.84
151.66
151.66
151.66
151.66
151.66
212.56
212.56
212.56
212.56
273.44
273.44
273.44
273.44
358.68
358.68
358.68
358.68
136.72
136.72
136.72
136.72
197.61
197.61
197.61
197.61
282.85
282.85
282.85
282.85
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
ALEUTIANS WEST
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
58.02
58.02
58.02
58.02
58.02
58.02
58.02
116.04
116.04
116.04
116.04
116.04
173.59
173.59
173.59
173.59
231.14
231.14
231.14
231.14
311.7
311.7
311.7
311.7
115.57
115.57
115.57
115.57
173.12
173.12
173.12
173.12
253.69
253.69
253.69
253.69
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
ALEUTIANS WEST
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
ANCHORAGE
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.61
75.61
75.61
75.61
75.61
75.61
75.61
151.22
151.22
151.22
151.22
151.22
211.93
211.93
211.93
211.93
272.64
272.64
272.64
272.64
357.63
357.63
357.63
357.63
136.32
136.32
136.32
136.32
197.03
197.03
197.03
197.03
282.01
282.01
282.01
282.01
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
ANCHORAGE
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
57.85
57.85
57.85
57.85
57.85
57.85
57.85
115.7
115.7
115.7
115.7
115.7
173.08
173.08
173.08
173.08
230.46
230.46
230.46
230.46
310.79
310.79
310.79
310.79
115.23
115.23
115.23
115.23
172.61
172.61
172.61
172.61
252.94
252.94
252.94
252.94
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
ANCHORAGE
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
BETHEL
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.61
75.61
75.61
75.61
75.61
75.61
75.61
151.22
151.22
151.22
151.22
151.22
211.93
211.93
211.93
211.93
272.64
272.64
272.64
272.64
357.63
357.63
357.63
357.63
136.32
136.32
136.32
136.32
197.03
197.03
197.03
197.03
282.01
282.01
282.01
282.01
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
BETHEL
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
57.85
57.85
57.85
57.85
57.85
57.85
57.85
115.7
115.7
115.7
115.7
115.7
173.08
173.08
173.08
173.08
230.46
230.46
230.46
230.46
310.79
310.79
310.79
310.79
115.23
115.23
115.23
115.23
172.61
172.61
172.61
172.61
252.94
252.94
252.94
252.94
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
BETHEL
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
BRISTOL BAY BOROUGH
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.84
75.84
75.84
75.84
75.84
75.84
75.84
151.66
151.66
151.66
151.66
151.66
212.56
212.56
212.56
212.56
273.44
273.44
273.44
273.44
358.68
358.68
358.68
358.68
136.72
136.72
136.72
136.72
197.61
197.61
197.61
197.61
282.85
282.85
282.85
282.85
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
BRISTOL BAY BOROUGH
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
58.02
58.02
58.02
58.02
58.02
58.02
58.02
116.04
116.04
116.04
116.04
116.04
173.59
173.59
173.59
173.59
231.14
231.14
231.14
231.14
311.7
311.7
311.7
311.7
115.57
115.57
115.57
115.57
173.12
173.12
173.12
173.12
253.69
253.69
253.69
253.69
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
BRISTOL BAY BOROUGH
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
DENALI
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.84
75.84
75.84
75.84
75.84
75.84
75.84
151.66
151.66
151.66
151.66
151.66
212.56
212.56
212.56
212.56
273.44
273.44
273.44
273.44
358.68
358.68
358.68
358.68
136.72
136.72
136.72
136.72
197.61
197.61
197.61
197.61
282.85
282.85
282.85
282.85
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
DENALI
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
58.02
58.02
58.02
58.02
58.02
58.02
58.02
116.04
116.04
116.04
116.04
116.04
173.59
173.59
173.59
173.59
231.14
231.14
231.14
231.14
311.7
311.7
311.7
311.7
115.57
115.57
115.57
115.57
173.12
173.12
173.12
173.12
253.69
253.69
253.69
253.69
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
DENALI
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
DILLINGHAM
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.61
75.61
75.61
75.61
75.61
75.61
75.61
151.22
151.22
151.22
151.22
151.22
211.93
211.93
211.93
211.93
272.64
272.64
272.64
272.64
357.63
357.63
357.63
357.63
136.32
136.32
136.32
136.32
197.03
197.03
197.03
197.03
282.01
282.01
282.01
282.01
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
DILLINGHAM
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
57.85
57.85
57.85
57.85
57.85
57.85
57.85
115.7
115.7
115.7
115.7
115.7
173.08
173.08
173.08
173.08
230.46
230.46
230.46
230.46
310.79
310.79
310.79
310.79
115.23
115.23
115.23
115.23
172.61
172.61
172.61
172.61
252.94
252.94
252.94
252.94
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
DILLINGHAM
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
FAIRBANKS NORTH STAR
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.84
75.84
75.84
75.84
75.84
75.84
75.84
151.66
151.66
151.66
151.66
151.66
212.56
212.56
212.56
212.56
273.44
273.44
273.44
273.44
358.68
358.68
358.68
358.68
136.72
136.72
136.72
136.72
197.61
197.61
197.61
197.61
282.85
282.85
282.85
282.85
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
FAIRBANKS NORTH STAR
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
58.02
58.02
58.02
58.02
58.02
58.02
58.02
116.04
116.04
116.04
116.04
116.04
173.59
173.59
173.59
173.59
231.14
231.14
231.14
231.14
311.7
311.7
311.7
311.7
115.57
115.57
115.57
115.57
173.12
173.12
173.12
173.12
253.69
253.69
253.69
253.69
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
FAIRBANKS NORTH STAR
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
HAINES
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
63.87
63.87
63.87
63.87
63.87
63.87
63.87
127.74
127.74
127.74
127.74
127.74
179.02
179.02
179.02
179.02
230.3
230.3
230.3
230.3
302.08
302.08
302.08
302.08
115.15
115.15
115.15
115.15
166.43
166.43
166.43
166.43
238.22
238.22
238.22
238.22
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
HAINES
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
48.87
48.87
48.87
48.87
48.87
48.87
48.87
97.73
97.73
97.73
97.73
97.73
146.19
146.19
146.19
146.19
194.67
194.67
194.67
194.67
262.52
262.52
262.52
262.52
97.34
97.34
97.34
97.34
145.8
145.8
145.8
145.8
213.66
213.66
213.66
213.66
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
HAINES
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
Hoonah-Angoon
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
63.87
63.87
63.87
63.87
63.87
63.87
63.87
127.74
127.74
127.74
127.74
127.74
179.02
179.02
179.02
179.02
230.3
230.3
230.3
230.3
302.08
302.08
302.08
302.08
115.15
115.15
115.15
115.15
166.43
166.43
166.43
166.43
238.22
238.22
238.22
238.22
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
Hoonah-Angoon
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
48.87
48.87
48.87
48.87
48.87
48.87
48.87
97.73
97.73
97.73
97.73
97.73
146.19
146.19
146.19
146.19
194.67
194.67
194.67
194.67
262.52
262.52
262.52
262.52
97.34
97.34
97.34
97.34
145.8
145.8
145.8
145.8
213.66
213.66
213.66
213.66
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
Hoonah-Angoon
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
JUNEAU
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
63.87
63.87
63.87
63.87
63.87
63.87
63.87
127.74
127.74
127.74
127.74
127.74
179.02
179.02
179.02
179.02
230.3
230.3
230.3
230.3
302.08
302.08
302.08
302.08
115.15
115.15
115.15
115.15
166.43
166.43
166.43
166.43
238.22
238.22
238.22
238.22
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
JUNEAU
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
48.87
48.87
48.87
48.87
48.87
48.87
48.87
97.73
97.73
97.73
97.73
97.73
146.19
146.19
146.19
146.19
194.67
194.67
194.67
194.67
262.52
262.52
262.52
262.52
97.34
97.34
97.34
97.34
145.8
145.8
145.8
145.8
213.66
213.66
213.66
213.66
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
JUNEAU
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
KENAI PENINSULA
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.84
75.84
75.84
75.84
75.84
75.84
75.84
151.66
151.66
151.66
151.66
151.66
212.56
212.56
212.56
212.56
273.44
273.44
273.44
273.44
358.68
358.68
358.68
358.68
136.72
136.72
136.72
136.72
197.61
197.61
197.61
197.61
282.85
282.85
282.85
282.85
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
KENAI PENINSULA
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
58.02
58.02
58.02
58.02
58.02
58.02
58.02
116.04
116.04
116.04
116.04
116.04
173.59
173.59
173.59
173.59
231.14
231.14
231.14
231.14
311.7
311.7
311.7
311.7
115.57
115.57
115.57
115.57
173.12
173.12
173.12
173.12
253.69
253.69
253.69
253.69
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
KENAI PENINSULA
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
KETCHIKAN GATEWAY
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
63.87
63.87
63.87
63.87
63.87
63.87
63.87
127.74
127.74
127.74
127.74
127.74
179.02
179.02
179.02
179.02
230.3
230.3
230.3
230.3
302.08
302.08
302.08
302.08
115.15
115.15
115.15
115.15
166.43
166.43
166.43
166.43
238.22
238.22
238.22
238.22
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
KETCHIKAN GATEWAY
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
48.87
48.87
48.87
48.87
48.87
48.87
48.87
97.73
97.73
97.73
97.73
97.73
146.19
146.19
146.19
146.19
194.67
194.67
194.67
194.67
262.52
262.52
262.52
262.52
97.34
97.34
97.34
97.34
145.8
145.8
145.8
145.8
213.66
213.66
213.66
213.66
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
KETCHIKAN GATEWAY
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
KODIAK ISLAND
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.84
75.84
75.84
75.84
75.84
75.84
75.84
151.66
151.66
151.66
151.66
151.66
212.56
212.56
212.56
212.56
273.44
273.44
273.44
273.44
358.68
358.68
358.68
358.68
136.72
136.72
136.72
136.72
197.61
197.61
197.61
197.61
282.85
282.85
282.85
282.85
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
KODIAK ISLAND
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
58.02
58.02
58.02
58.02
58.02
58.02
58.02
116.04
116.04
116.04
116.04
116.04
173.59
173.59
173.59
173.59
231.14
231.14
231.14
231.14
311.7
311.7
311.7
311.7
115.57
115.57
115.57
115.57
173.12
173.12
173.12
173.12
253.69
253.69
253.69
253.69
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
KODIAK ISLAND
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
LAKE AND PENINSULA
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.84
75.84
75.84
75.84
75.84
75.84
75.84
151.66
151.66
151.66
151.66
151.66
212.56
212.56
212.56
212.56
273.44
273.44
273.44
273.44
358.68
358.68
358.68
358.68
136.72
136.72
136.72
136.72
197.61
197.61
197.61
197.61
282.85
282.85
282.85
282.85
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
LAKE AND PENINSULA
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
58.02
58.02
58.02
58.02
58.02
58.02
58.02
116.04
116.04
116.04
116.04
116.04
173.59
173.59
173.59
173.59
231.14
231.14
231.14
231.14
311.7
311.7
311.7
311.7
115.57
115.57
115.57
115.57
173.12
173.12
173.12
173.12
253.69
253.69
253.69
253.69
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
LAKE AND PENINSULA
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
MATANUSKA-SUSITNA
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.84
75.84
75.84
75.84
75.84
75.84
75.84
151.66
151.66
151.66
151.66
151.66
212.56
212.56
212.56
212.56
273.44
273.44
273.44
273.44
358.68
358.68
358.68
358.68
136.72
136.72
136.72
136.72
197.61
197.61
197.61
197.61
282.85
282.85
282.85
282.85
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
MATANUSKA-SUSITNA
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
58.02
58.02
58.02
58.02
58.02
58.02
58.02
116.04
116.04
116.04
116.04
116.04
173.59
173.59
173.59
173.59
231.14
231.14
231.14
231.14
311.7
311.7
311.7
311.7
115.57
115.57
115.57
115.57
173.12
173.12
173.12
173.12
253.69
253.69
253.69
253.69
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
MATANUSKA-SUSITNA
Low
Delta Dental of Alaska
21989AK0010001
Premier
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-888-873-1395
1-888-873-1395
1-888-873-1395
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml?dn=ods
https://www.modahealth.com/pdfs/ak/members/2014/ind_health_plan_brochure.pdf
https://www.modahealth.com/pdfs/plans/individual/ModaHealth_Premier_dental_AK_2014.pdf
X
X
X
X
X
X
X
29
32
32
32
32
32
32
64
64
64
64
64
93
93
93
93
122
122
122
122
151
151
151
151
61
61
61
61
90
90
90
90
119
119
119
119
0
$0
700
1400
20%
40%
50%
Not Covered
20%
40%
50%
0.5
AK
NOME
Low
BEST Life
74819AK0020005
BEST Dental Plus - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Plus_Plan_(Silver).pdf
X
X
X
X
X
X
X
75.84
75.84
75.84
75.84
75.84
75.84
75.84
151.66
151.66
151.66
151.66
151.66
212.56
212.56
212.56
212.56
273.44
273.44
273.44
273.44
358.68
358.68
358.68
358.68
136.72
136.72
136.72
136.72
197.61
197.61
197.61
197.61
282.85
282.85
282.85
282.85
50
See Plan Brochure
700
1400
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5
AK
NOME
Low
BEST Life
74819AK0020006
BEST Dental Basic - Silver
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www2.dentemax.com/
http://www.bestlife.com/AK/pdf/AK_BESTOne_Dental_Basic_Plan_(Silver).pdf
X
X
X
X
X
X
X
58.02
58.02
58.02
58.02
58.02
58.02
58.02
116.04
116.04
116.04
116.04
116.04
173.59
173.59
173.59
173.59
231.14
231.14
231.14
231.14
311.7
311.7
311.7
311.7
115.57
115.57
115.57
115.57
173.12
173.12
173.12
173.12
253.69
253.69
253.69
253.69
50
See Plan Brochure
700
1400
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
45% Coinsurance after deductible
65% Coinsurance after deductible
0.5

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