Namara Marketplace

2017 QHP Landscape Individual 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
74819AK0020005
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
52.68
56.28
56.28
56.28
56.28
56.28
105.36
112.56
112.56
112.56
112.56
153.07
160.27
160.27
160.27
200.78
207.98
207.98
207.98
248.49
255.69
255.69
255.69
100.39
103.99
103.99
103.99
148.1
151.7
151.7
151.7
195.81
199.41
199.41
199.41
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
AK
02013
Aleutians East
Low
BEST Life and Health Insurance Company
74819
74819AK0020006
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
37.86
40.45
40.45
40.45
40.45
40.45
75.72
80.9
80.9
80.9
80.9
123.43
128.61
128.61
128.61
171.14
176.32
176.32
176.32
218.85
224.03
224.03
224.03
85.57
88.16
88.16
88.16
133.28
135.87
135.87
135.87
180.99
183.58
183.58
183.58
75
See Plan Brochure
75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AK
02016
Aleutians West
Low
BEST Life and Health Insurance Company
74819
74819AK0020005
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
52.68
56.28
56.28
56.28
56.28
56.28
105.36
112.56
112.56
112.56
112.56
153.07
160.27
160.27
160.27
200.78
207.98
207.98
207.98
248.49
255.69
255.69
255.69
100.39
103.99
103.99
103.99
148.1
151.7
151.7
151.7
195.81
199.41
199.41
199.41
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
AK
02016
Aleutians West
Low
BEST Life and Health Insurance Company
74819
74819AK0020006
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
37.86
40.45
40.45
40.45
40.45
40.45
75.72
80.9
80.9
80.9
80.9
123.43
128.61
128.61
128.61
171.14
176.32
176.32
176.32
218.85
224.03
224.03
224.03
85.57
88.16
88.16
88.16
133.28
135.87
135.87
135.87
180.99
183.58
183.58
183.58
75
See Plan Brochure
75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AK
02016
Aleutians West
Low
Oregon Dental Service
21989
21989AK0030001
Delta Dental Premier Plan
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/plans/individual/Moda_DeltaDentalPremierPlan_2017_AK.pdf
X
X
X
X
X
X
X
44
39
39
39
39
39
39
78
78
78
78
78
122
122
122
122
166
166
166
166
210
210
210
210
83
83
83
83
127
127
127
127
171
171
171
171
0
$0
0
350
700
350
20%
35%
50%
Not Covered
20%
35%
50%
0.5
AK
02020
Anchorage
High
BEST Life and Health Insurance Company
74819
74819AK0020003
BESTOne Advantage Gold
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/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
61.64
66.59
71.14
71.14
71.14
71.14
71.14
133.18
142.28
142.28
142.28
142.28
194.82
203.92
203.92
203.92
256.46
265.56
265.56
265.56
318.1
327.2
327.2
327.2
128.23
132.78
132.78
132.78
189.87
194.42
194.42
194.42
251.51
256.06
256.06
256.06
50
$150
50
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
AK
02020
Anchorage
High
BEST Life and Health Insurance Company
74819
74819AK0020004
BESTOne Plus Gold
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/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
61.64
55.37
59.15
59.15
59.15
59.15
59.15
110.74
118.3
118.3
118.3
118.3
172.38
179.94
179.94
179.94
234.02
241.58
241.58
241.58
295.66
303.22
303.22
303.22
117.01
120.79
120.79
120.79
178.65
182.43
182.43
182.43
240.29
244.07
244.07
244.07
50
$150
50
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
AK
02020
Anchorage
High
Oregon Dental Service
21989
21989AK0050001
Delta Dental PPO 1000 Plan
PPO
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/plans/individual/Moda_DeltaDentalPPO1000Plan_2017_AK.pdf
X
X
X
X
X
X
X
39
36
36
36
36
36
36
72
72
72
72
72
111
111
111
111
150
150
150
150
189
189
189
189
75
75
75
75
114
114
114
114
153
153
153
153
0
$0
0
350
700
350
No Charge
20%
50%
Not Covered
No Charge
20%
50%
0.5
AK
02020
Anchorage
High
Oregon Dental Service
21989
21989AK0050002
Delta Dental PPO 1500 Plan
PPO
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/plans/individual/Moda_DeltaDentalPPO1500Plan_2017_AK.pdf
X
X
X
X
X
X
X
39
42
42
42
42
42
42
84
84
84
84
84
123
123
123
123
162
162
162
162
201
201
201
201
81
81
81
81
120
120
120
120
159
159
159
159
0
$0
0
350
700
350
No Charge
20%
50%
Not Covered
No Charge
20%
50%
0.5
AK
02020
Anchorage
Low
Oregon Dental Service
21989
21989AK0030001
Delta Dental Premier Plan
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/plans/individual/Moda_DeltaDentalPremierPlan_2017_AK.pdf
X
X
X
X
X
X
X
44
39
39
39
39
39
39
78
78
78
78
78
122
122
122
122
166
166
166
166
210
210
210
210
83
83
83
83
127
127
127
127
171
171
171
171
0
$0
0
350
700
350
20%
35%
50%
Not Covered
20%
35%
50%
0.5
AK
02050
Bethel
Low
BEST Life and Health Insurance Company
74819
74819AK0020005
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
52.68
56.28
56.28
56.28
56.28
56.28
105.36
112.56
112.56
112.56
112.56
153.07
160.27
160.27
160.27
200.78
207.98
207.98
207.98
248.49
255.69
255.69
255.69
100.39
103.99
103.99
103.99
148.1
151.7
151.7
151.7
195.81
199.41
199.41
199.41
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
AK
02050
Bethel
Low
BEST Life and Health Insurance Company
74819
74819AK0020006
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
37.86
40.45
40.45
40.45
40.45
40.45
75.72
80.9
80.9
80.9
80.9
123.43
128.61
128.61
128.61
171.14
176.32
176.32
176.32
218.85
224.03
224.03
224.03
85.57
88.16
88.16
88.16
133.28
135.87
135.87
135.87
180.99
183.58
183.58
183.58
75
See Plan Brochure
75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AK
02060
Bristol Bay
Low
BEST Life and Health Insurance Company
74819
74819AK0020005
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
52.68
56.28
56.28
56.28
56.28
56.28
105.36
112.56
112.56
112.56
112.56
153.07
160.27
160.27
160.27
200.78
207.98
207.98
207.98
248.49
255.69
255.69
255.69
100.39
103.99
103.99
103.99
148.1
151.7
151.7
151.7
195.81
199.41
199.41
199.41
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
AK
02060
Bristol Bay
Low
BEST Life and Health Insurance Company
74819
74819AK0020006
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
37.86
40.45
40.45
40.45
40.45
40.45
75.72
80.9
80.9
80.9
80.9
123.43
128.61
128.61
128.61
171.14
176.32
176.32
176.32
218.85
224.03
224.03
224.03
85.57
88.16
88.16
88.16
133.28
135.87
135.87
135.87
180.99
183.58
183.58
183.58
75
See Plan Brochure
75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AK
02090
Fairbanks North Star
Low
BEST Life and Health Insurance Company
74819
74819AK0020005
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
52.68
56.28
56.28
56.28
56.28
56.28
105.36
112.56
112.56
112.56
112.56
153.07
160.27
160.27
160.27
200.78
207.98
207.98
207.98
248.49
255.69
255.69
255.69
100.39
103.99
103.99
103.99
148.1
151.7
151.7
151.7
195.81
199.41
199.41
199.41
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
AK
02090
Fairbanks North Star
Low
BEST Life and Health Insurance Company
74819
74819AK0020006
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
37.86
40.45
40.45
40.45
40.45
40.45
75.72
80.9
80.9
80.9
80.9
123.43
128.61
128.61
128.61
171.14
176.32
176.32
176.32
218.85
224.03
224.03
224.03
85.57
88.16
88.16
88.16
133.28
135.87
135.87
135.87
180.99
183.58
183.58
183.58
75
See Plan Brochure
75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AK
02090
Fairbanks North Star
Low
Oregon Dental Service
21989
21989AK0030001
Delta Dental Premier Plan
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/plans/individual/Moda_DeltaDentalPremierPlan_2017_AK.pdf
X
X
X
X
X
X
X
44
39
39
39
39
39
39
78
78
78
78
78
122
122
122
122
166
166
166
166
210
210
210
210
83
83
83
83
127
127
127
127
171
171
171
171
0
$0
0
350
700
350
20%
35%
50%
Not Covered
20%
35%
50%
0.5
AK
02100
Haines
Low
Oregon Dental Service
21989
21989AK0030001
Delta Dental Premier Plan
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/plans/individual/Moda_DeltaDentalPremierPlan_2017_AK.pdf
X
X
X
X
X
X
X
44
39
39
39
39
39
39
78
78
78
78
78
122
122
122
122
166
166
166
166
210
210
210
210
83
83
83
83
127
127
127
127
171
171
171
171
0
$0
0
350
700
350
20%
35%
50%
Not Covered
20%
35%
50%
0.5
AK
02105
Hoonah Angoon
Low
BEST Life and Health Insurance Company
74819
74819AK0020005
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
46.86
51.74
55.28
55.28
55.28
55.28
55.28
103.48
110.56
110.56
110.56
110.56
150.34
157.42
157.42
157.42
197.2
204.28
204.28
204.28
244.06
251.14
251.14
251.14
98.6
102.14
102.14
102.14
145.46
149
149
149
192.32
195.86
195.86
195.86
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
AK
02105
Hoonah Angoon
Low
BEST Life and Health Insurance Company
74819
74819AK0020006
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
46.86
37.18
39.73
39.73
39.73
39.73
39.73
74.36
79.46
79.46
79.46
79.46
121.22
126.32
126.32
126.32
168.08
173.18
173.18
173.18
214.94
220.04
220.04
220.04
84.04
86.59
86.59
86.59
130.9
133.45
133.45
133.45
177.76
180.31
180.31
180.31
75
See Plan Brochure
75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AK
02110
Juneau
High
BEST Life and Health Insurance Company
74819
74819AK0020003
BESTOne Advantage Gold
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/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
60.54
65.4
69.87
69.87
69.87
69.87
69.87
130.8
139.74
139.74
139.74
139.74
191.34
200.28
200.28
200.28
251.88
260.82
260.82
260.82
312.42
321.36
321.36
321.36
125.94
130.41
130.41
130.41
186.48
190.95
190.95
190.95
247.02
251.49
251.49
251.49
50
$150
50
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
AK
02110
Juneau
High
BEST Life and Health Insurance Company
74819
74819AK0020004
BESTOne Plus Gold
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/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
60.54
54.38
58.1
58.1
58.1
58.1
58.1
108.76
116.2
116.2
116.2
116.2
169.3
176.74
176.74
176.74
229.84
237.28
237.28
237.28
290.38
297.82
297.82
297.82
114.92
118.64
118.64
118.64
175.46
179.18
179.18
179.18
236
239.72
239.72
239.72
50
$150
50
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
AK
02110
Juneau
Low
Oregon Dental Service
21989
21989AK0030001
Delta Dental Premier Plan
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/plans/individual/Moda_DeltaDentalPremierPlan_2017_AK.pdf
X
X
X
X
X
X
X
44
39
39
39
39
39
39
78
78
78
78
78
122
122
122
122
166
166
166
166
210
210
210
210
83
83
83
83
127
127
127
127
171
171
171
171
0
$0
0
350
700
350
20%
35%
50%
Not Covered
20%
35%
50%
0.5
AK
02130
Ketchikan Gateway
High
BEST Life and Health Insurance Company
74819
74819AK0020003
BESTOne Advantage Gold
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/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
60.54
65.4
69.87
69.87
69.87
69.87
69.87
130.8
139.74
139.74
139.74
139.74
191.34
200.28
200.28
200.28
251.88
260.82
260.82
260.82
312.42
321.36
321.36
321.36
125.94
130.41
130.41
130.41
186.48
190.95
190.95
190.95
247.02
251.49
251.49
251.49
50
$150
50
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
AK
02130
Ketchikan Gateway
High
BEST Life and Health Insurance Company
74819
74819AK0020004
BESTOne Plus Gold
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/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
60.54
54.38
58.1
58.1
58.1
58.1
58.1
108.76
116.2
116.2
116.2
116.2
169.3
176.74
176.74
176.74
229.84
237.28
237.28
237.28
290.38
297.82
297.82
297.82
114.92
118.64
118.64
118.64
175.46
179.18
179.18
179.18
236
239.72
239.72
239.72
50
$150
50
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
AK
02170
Matanuska Susitna
Low
Oregon Dental Service
21989
21989AK0030001
Delta Dental Premier Plan
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/plans/individual/Moda_DeltaDentalPremierPlan_2017_AK.pdf
X
X
X
X
X
X
X
44
39
39
39
39
39
39
78
78
78
78
78
122
122
122
122
166
166
166
166
210
210
210
210
83
83
83
83
127
127
127
127
171
171
171
171
0
$0
0
350
700
350
20%
35%
50%
Not Covered
20%
35%
50%
0.5
AK
02180
Nome
Low
BEST Life and Health Insurance Company
74819
74819AK0020005
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
52.68
56.28
56.28
56.28
56.28
56.28
105.36
112.56
112.56
112.56
112.56
153.07
160.27
160.27
160.27
200.78
207.98
207.98
207.98
248.49
255.69
255.69
255.69
100.39
103.99
103.99
103.99
148.1
151.7
151.7
151.7
195.81
199.41
199.41
199.41
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
AK
02180
Nome
Low
BEST Life and Health Insurance Company
74819
74819AK0020006
BESTOne 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://www.bestlife.com/Provider_Search/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Basic-Silver_Plan.pdf
X
X
X
X
X
X
X
47.71
37.86
40.45
40.45
40.45
40.45
40.45
75.72
80.9
80.9
80.9
80.9
123.43
128.61
128.61
128.61
171.14
176.32
176.32
176.32
218.85
224.03
224.03
224.03
85.57
88.16
88.16
88.16
133.28
135.87
135.87
135.87
180.99
183.58
183.58
183.58
75
See Plan Brochure
75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AK
02180
Nome
Low
Oregon Dental Service
21989
21989AK0030001
Delta Dental Premier Plan
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/plans/individual/Moda_DeltaDentalPremierPlan_2017_AK.pdf
X
X
X
X
X
X
X
44
39
39
39
39
39
39
78
78
78
78
78
122
122
122
122
166
166
166
166
210
210
210
210
83
83
83
83
127
127
127
127
171
171
171
171
0
$0
0
350
700
350
20%
35%
50%
Not Covered
20%
35%
50%
0.5
AK
02188
Northwest Arctic
High
BEST Life and Health Insurance Company
74819
74819AK0020003
BESTOne Advantage Gold
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/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
61.64
66.59
71.14
71.14
71.14
71.14
71.14
133.18
142.28
142.28
142.28
142.28
194.82
203.92
203.92
203.92
256.46
265.56
265.56
265.56
318.1
327.2
327.2
327.2
128.23
132.78
132.78
132.78
189.87
194.42
194.42
194.42
251.51
256.06
256.06
256.06
50
$150
50
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
AK
02188
Northwest Arctic
High
BEST Life and Health Insurance Company
74819
74819AK0020004
BESTOne Plus Gold
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/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
61.64
55.37
59.15
59.15
59.15
59.15
59.15
110.74
118.3
118.3
118.3
118.3
172.38
179.94
179.94
179.94
234.02
241.58
241.58
241.58
295.66
303.22
303.22
303.22
117.01
120.79
120.79
120.79
178.65
182.43
182.43
182.43
240.29
244.07
244.07
244.07
50
$150
50
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
AK
02198
Prince Of Wales Hyder
Low
Oregon Dental Service
21989
21989AK0030001
Delta Dental Premier Plan
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/plans/individual/Moda_DeltaDentalPremierPlan_2017_AK.pdf
X
X
X
X
X
X
X
44
39
39
39
39
39
39
78
78
78
78
78
122
122
122
122
166
166
166
166
210
210
210
210
83
83
83
83
127
127
127
127
171
171
171
171
0
$0
0
350
700
350
20%
35%
50%
Not Covered
20%
35%
50%
0.5
AK
02270
Wade Hampton
High
BEST Life and Health Insurance Company
74819
74819AK0020003
BESTOne Advantage Gold
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/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
61.64
66.59
71.14
71.14
71.14
71.14
71.14
133.18
142.28
142.28
142.28
142.28
194.82
203.92
203.92
203.92
256.46
265.56
265.56
265.56
318.1
327.2
327.2
327.2
128.23
132.78
132.78
132.78
189.87
194.42
194.42
194.42
251.51
256.06
256.06
256.06
50
$150
50
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
AK
02270
Wade Hampton
High
BEST Life and Health Insurance Company
74819
74819AK0020004
BESTOne Plus Gold
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/
https://www.bestlife.com/ak/2017/AK_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
61.64
55.37
59.15
59.15
59.15
59.15
59.15
110.74
118.3
118.3
118.3
118.3
172.38
179.94
179.94
179.94
234.02
241.58
241.58
241.58
295.66
303.22
303.22
303.22
117.01
120.79
120.79
120.79
178.65
182.43
182.43
182.43
240.29
244.07
244.07
244.07
50
$150
50
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
AK
02282
Yakutat
Low
Oregon Dental Service
21989
21989AK0030001
Delta Dental Premier Plan
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/plans/individual/Moda_DeltaDentalPremierPlan_2017_AK.pdf
X
X
X
X
X
X
X
44
39
39
39
39
39
39
78
78
78
78
78
122
122
122
122
166
166
166
166
210
210
210
210
83
83
83
83
127
127
127
127
171
171
171
171
0
$0
0
350
700
350
20%
35%
50%
Not Covered
20%
35%
50%
0.5
AK
02290
Yukon Koyukuk
Low
Oregon Dental Service
21989
21989AK0030001
Delta Dental Premier Plan
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/plans/individual/Moda_DeltaDentalPremierPlan_2017_AK.pdf
X
X
X
X
X
X
X
44
39
39
39
39
39
39
78
78
78
78
78
122
122
122
122
166
166
166
166
210
210
210
210
83
83
83
83
127
127
127
127
171
171
171
171
0
$0
0
350
700
350
20%
35%
50%
Not Covered
20%
35%
50%
0.5
AL
01001
Autauga
High
Delta Dental Insurance Company
82285
82285AL0010004
Delta Dental PPO Preferred Plan for Families
PPO
Rating Area 11
Allows Adult and Child-Only
HIOS
1-800-471-0236
1-800-471-0236
1-800-471-0236
https://www.deltadentalins.com/find-a-dentist
https://deltadentalins.com/hcx/al/82285al0010004-17
X
X
X
X
X
X
X
25.37
38.86
38.86
38.86
38.86
38.86
38.86
77.72
77.72
77.72
77.72
77.72
103.09
103.09
103.09
103.09
128.46
128.46
128.46
128.46
153.83
153.83
153.83
153.83
64.23
64.23
64.23
64.23
89.6
89.6
89.6
89.6
114.97
114.97
114.97
114.97
25
See Plan Brochure
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AL
01001
Autauga
High
TRUASSURE INSURANCE COMPANY
60075
60075AL0020001
TruAssure Preferred Adult or Child Dental Plan
PPO
Rating Area 11
Allows Adult and Child-Only
HIOS
1-888-559-0781
1-888-559-0781
1-800-526-0844
https://www.truassure.com/find-a-provider
https://www.truassure.com/brochure?state=AL
https://www.truassure.com/plan-information2?state=AL
X
X
X
X
X
X
X
31.36
32.06
32.06
32.06
32.06
32.06
32.06
64.12
64.12
64.12
64.12
64.12
95.48
95.48
95.48
95.48
126.84
126.84
126.84
126.84
158.2
158.2
158.2
158.2
63.42
63.42
63.42
63.42
94.78
94.78
94.78
94.78
126.14
126.14
126.14
126.14
25
See Plan Brochure
25
350
700
350
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AL
01001
Autauga
Low
Blue Cross and Blue Shield of Alabama
46944
46944AL0500001
Dental Blue Plus
PPO
Rating Area 11
Allows Adult and Child-Only
HIOS
1-855-350-7437
1-855-350-7437
https://www.bcbsal.org/webapps/providerfinderplus
X
X
X
X
X
X
X
33
23
23
23
23
23
23
46
46
46
46
46
79
79
79
79
112
112
112
112
145
145
145
145
56
56
56
56
89
89
89
89
122
122
122
122
40
See Plan Brochure
40
350
700
350
No Charge after Deductible
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge after Deductible
20% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AL
01003
Baldwin
Low
BEST Life and Health Insurance Company
12538
12538AL0020005
BESTOne Plus Silver
PPO
Rating Area 13
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
https://www.bestlife.com/AL/2017/AL_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
21.44
23.01
24.59
24.59
24.59
24.59
24.59
46.02
49.18
49.18
49.18
49.18
67.46
70.62
70.62
70.62
88.9
92.06
92.06
92.06
110.34
113.5
113.5
113.5
44.45
46.03
46.03
46.03
65.89
67.47
67.47
67.47
87.33
88.91
88.91
88.91
75
See Plan Brochure
75
350
700
350
No Charge
30% Coinsurance after deductible
60% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AL
01003
Baldwin
Low
BEST Life and Health Insurance Company
12538
12538AL0020006
BESTOne Basic Silver
PPO
Rating Area 13
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
https://www.bestlife.com/AL/2017/AL_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
21.44
16.53
17.67
17.67
17.67
17.67
17.67
33.06
35.34
35.34
35.34
35.34
54.5
56.78
56.78
56.78
75.94
78.22
78.22
78.22
97.38
99.66
99.66
99.66
37.97
39.11
39.11
39.11
59.41
60.55
60.55
60.55
80.85
81.99
81.99
81.99
75
See Plan Brochure
75
350
700
350
No Charge
50% Coinsurance after deductible
70% Coinsurance after deductible
Not Covered
No Charge after Deductible
30% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AL
01003
Baldwin
Low
TRUASSURE INSURANCE COMPANY
60075
60075AL0010001
TruAssure Basic Adult or Child Dental Plan
PPO
Rating Area 13
Allows Adult and Child-Only
HIOS
1-888-559-0781
1-888-559-0781
1-800-526-0844
https://www.truassure.com/find-a-provider
https://www.truassure.com/brochure?state=AL
https://www.truassure.com/plan-information2?state=AL
X
X
X
X
X
X
25.75
19.37
19.37
19.37
19.37
19.37
19.37
38.74
38.74
38.74
38.74
38.74
64.49
64.49
64.49
64.49
90.24
90.24
90.24
90.24
115.99
115.99
115.99
115.99
45.12
45.12
45.12
45.12
70.87
70.87
70.87
70.87
96.62
96.62
96.62
96.62
85
See Plan Brochure
85
350
700
350
No Charge
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AL
01007
Bibb
Low
Delta Dental Insurance Company
82285
82285AL0010006
Delta Dental PPO Basic Plan for Families
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-800-471-0236
1-800-471-0236
1-800-471-0236
https://www.deltadentalins.com/find-a-dentist
https://deltadentalins.com/hcx/al/82285al0010006-17
X
X
X
X
X
X
20.58
16.44
16.44
16.44
16.44
16.44
16.44
32.88
32.88
32.88
32.88
32.88
53.46
53.46
53.46
53.46
74.04
74.04
74.04
74.04
94.62
94.62
94.62
94.62
37.02
37.02
37.02
37.02
57.6
57.6
57.6
57.6
78.18
78.18
78.18
78.18
50
See Plan Brochure
350
700
350
0% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
Not Covered
0% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AL
01009
Blount
High
BEST Life and Health Insurance Company
12538
12538AL0020003
BESTOne Advantage Gold
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/
https://www.bestlife.com/AL/2017/AL_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
27.6
28.97
30.96
30.96
30.96
30.96
30.96
57.94
61.92
61.92
61.92
61.92
85.54
89.52
89.52
89.52
113.14
117.12
117.12
117.12
140.74
144.72
144.72
144.72
56.57
58.56
58.56
58.56
84.17
86.16
86.16
86.16
111.77
113.76
113.76
113.76
50
See Plan Brochure
50
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
AL
01009
Blount
High
BEST Life and Health Insurance Company
12538
12538AL0020004
BESTOne Plus Gold
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/
https://www.bestlife.com/AL/2017/AL_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
27.6
24.1
25.75
25.75
25.75
25.75
25.75
48.2
51.5
51.5
51.5
51.5
75.8
79.1
79.1
79.1
103.4
106.7
106.7
106.7
131
134.3
134.3
134.3
51.7
53.35
53.35
53.35
79.3
80.95
80.95
80.95
106.9
108.55
108.55
108.55
50
See Plan Brochure
50
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
AL
01009
Blount
High
Delta Dental Insurance Company
82285
82285AL0010004
Delta Dental PPO Preferred Plan for Families
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-800-471-0236
1-800-471-0236
1-800-471-0236
https://www.deltadentalins.com/find-a-dentist
https://deltadentalins.com/hcx/al/82285al0010004-17
X
X
X
X
X
X
X
26.26
40.22
40.22
40.22
40.22
40.22
40.22
80.44
80.44
80.44
80.44
80.44
106.7
106.7
106.7
106.7
132.96
132.96
132.96
132.96
159.22
159.22
159.22
159.22
66.48
66.48
66.48
66.48
92.74
92.74
92.74
92.74
119
119
119
119
25
See Plan Brochure
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AL
01009
Blount
Low
Humana Insurance Company
44580
44580AL0380001
Humana Dental Smart Choice
PPO
Rating Area 3
Allows Adult and Child-Only
HIOS
1-877-720-4854
1-877-720-4854
711
https://www.humana.com/finder/search?customerId=1085&pfpkey=317
http://apps.humana.com/marketing/documents.asp?file=2856971
X
X
X
X
X
X
19.21
15
15.47
15.47
15.47
15.47
15.93
30
30.94
30.94
30.94
31.86
49.21
50.15
50.15
50.15
68.42
69.36
69.36
69.36
87.63
88.57
88.57
88.57
34.21
34.68
34.68
34.68
53.42
53.89
53.89
53.89
72.63
73.1
73.1
73.1
35
See Plan Brochure
350
700
350
No Charge
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
0.5
AL
01011
Bullock
High
BEST Life and Health Insurance Company
12538
12538AL0020003
BESTOne Advantage Gold
PPO
Rating Area 13
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
https://www.bestlife.com/AL/2017/AL_BESTOne_Dental_Advantage-Gold_Plan.pdf
X
X
X
X
X
X
X
27.7
29.07
31.06
31.06
31.06
31.06
31.06
58.14
62.12
62.12
62.12
62.12
85.84
89.82
89.82
89.82
113.54
117.52
117.52
117.52
141.24
145.22
145.22
145.22
56.77
58.76
58.76
58.76
84.47
86.46
86.46
86.46
112.17
114.16
114.16
114.16
50
See Plan Brochure
50
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
AL
01011
Bullock
High
BEST Life and Health Insurance Company
12538
12538AL0020004
BESTOne Plus Gold
PPO
Rating Area 13
Allows Adult and Child-Only
HIOS
1-949-253-4080
1-800-433-0088
1-949-222-2134
http://www.bestlife.com/Provider_Search/
https://www.bestlife.com/AL/2017/AL_BESTOne_Dental_Plus-Gold_Plan.pdf
X
X
X
X
X
X
X
27.7
24.18
25.84
25.84
25.84
25.84
25.84
48.36
51.68
51.68
51.68
51.68
76.06
79.38
79.38
79.38
103.76
107.08
107.08
107.08
131.46
134.78
134.78
134.78
51.88
53.54
53.54
53.54
79.58
81.24
81.24
81.24
107.28
108.94
108.94
108.94
50
See Plan Brochure
50
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
AL
01011
Bullock
High
Delta Dental Insurance Company
82285
82285AL0010004
Delta Dental PPO Preferred Plan for Families
PPO
Rating Area 13
Allows Adult and Child-Only
HIOS
1-800-471-0236
1-800-471-0236
1-800-471-0236
https://www.deltadentalins.com/find-a-dentist
https://deltadentalins.com/hcx/al/82285al0010004-17
X
X
X
X
X
X
X
25.23
38.65
38.65
38.65
38.65
38.65
38.65
77.3
77.3
77.3
77.3
77.3
102.53
102.53
102.53
102.53
127.76
127.76
127.76
127.76
152.99
152.99
152.99
152.99
63.88
63.88
63.88
63.88
89.11
89.11
89.11
89.11
114.34
114.34
114.34
114.34
25
See Plan Brochure
350
700
350
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
No Charge
20% Coinsurance after deductible
50% Coinsurance after deductible
0.5

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