The plans advertised herein offer supplemental insurance coverage and are not major medical insurance plans.
Dental, Vision, Hearing (DVH): Policy Series T80000 - In Arkansas, Policy T80000AR. In Delaware, Policy T80000. In Idaho, Policy T80000ID. In Oklahoma, Policy T80000OK. In Oregon, Policy T80000OR. In Pennsylvania, Policy T80000PA. In Texas, Policy T80000TX.
This is a brief product overview only. Coverage may not be available in all states including but not limited to New York and Virginia. Benefits/premium rates may vary based on plan selected. Optional riders are available at an additional cost. The policy has limitations and exclusions that may affect benefits payable. Refer to the policy for complete details, limitations, and exclusions. For costs and complete details of the coverage, please contact your local Aflac agent.
NOTICE: The coverage offered is not a qualified health plan (QHP) under the Patient Protection and Affordable Care Act (ACA) and is not required to satisfy essential health benefits mandates of the ACA. The coverage provides limited benefits.
Limitations and Exclusions for Arizona
This policy may be voided and benefits are not paid whenever: (1) material facts or circumstances have been concealed or misrepresented in making a claim under this policy; or (2) fraud is committed or attempted in connection with any matter relating to this policy. If you have received benefits that were not contractually due under this policy, then any benefits payable under this policy may be offset up to the amount of benefits you received that were not contractually due.
If you fail to cooperate with our investigation into the validity of your claim, benefits are not covered.
Benefits for a prosthetic device that replaces teeth that a Covered Person lost prior to the Effective Date are not covered, unless the device also replaces one or more natural teeth lost or extracted while covered under this policy.
Benefits for the replacement of congenitally missing teeth are not covered, unless you are replacing a current fixed bridge or denture. Such replacement is subject to policy replacement limits.
Benefits are not covered for:
- Any dental procedure or treatment not approved by the American Dental Association or which is clearly experimental in nature;
- Items, treatments, or services not listed in the Policy Schedule;
- Items, treatments, or services not prescribed by or performed under the direct supervision of a Dentist or Provider;
- Items, treatments, or services that are not Medically Necessary;
- Charges in excess of the Usual and Customary Charges;
- Treatment that results from participation in, or attempting to participate in, an illegal activity that is defined as a felony, whether charged or not (“felony” is as defined by the law of the jurisdiction in which the activity takes place); or being incarcerated in any detention facility or penal institution;
- Treatment resulting from an intentionally self-inflicted bodily injury, or committing or attempting suicide, while sane or insane;
- Cosmetic surgery or other elective procedures that are not Medically Necessary;
- Orthodontic treatment; [implantology and related services; implants and all related procedures, including removal of implants;]
- Charges for any appliance or service that is used to change vertical dimension, restore or maintain occlusion, split or stabilize teeth for periodontal reasons, or treat disturbances of the temporomandibular joint (TMJ), unless mandated by state law;
- Charges for any service performed as a result of abrasion, attrition, bruxism, erosion, or abfraction;
- [Occlusal, athletic, or night guards;]
- Preventive root canal therapy;
- Full mouth debridement;
- Charges for any services that are considered to be an integral part of another service, such as pulp capping;
- Surgical trays, or sutures;
- Ridge preservation, augmentation, bone grafts, and regeneration procedures performed in edentulous sites;
- Overdentures or precision attachments;
- Space maintainers;
- Sealants for a Covered Person over the age of 16;
- Preparation and fitting of preformed dowel or post for root canal tooth; pulp cap either directly or indirectly;
- Duplicate or temporary devices, appliances, and services except as listed as a Covered Expense;
- Replacing a lost, stolen, or missing appliance or prosthetic device;
- Application of chemotherapeutic agents;
- Oral hygiene instruction, plaque control, diet instruction or infection control;
- Charges for sterilization of equipment, disposal of medical waste, or other requirements mandated by OSHA or other regulatory agencies;
- Treatment received while outside the territorial limits of the United States;
- Treatment of a condition that results from an on-the-job or job-related illness or injury;
- Treatment of a condition for which benefits are payable by Workers’ Compensation or similar laws, whether or not benefits are claimed;
- Treatment for which no charge is made or for which you are not legally obligated to pay, except Medicaid or similar state-sponsored programs;
- Telephone consultations and teledentistry;
- Charges for failure to keep a scheduled appointment, x-ray copy fees, or charges for completion of a claim form;
- Ancillary charges, including but not limited to, hospital, ambulatory surgical center or similar facility, or use of Provider office space;
- Impacted wisdom teeth;
- Prescription drugs;
- [Any surgical procedure performed in the treatment of cataracts;]
- Treatment that occurs while this policy is not in force.
Limitations and Exclusions for Idaho
Benefits for services rendered by you or a member of the Immediate Family of a Covered Person are not covered.
This policy may be voided and benefits are not paid whenever: (1) material facts or circumstances have been concealed or misrepresented in making a claim under this policy; or (2) fraud is committed or attempted in connection with any matter relating to this policy. If you have received benefits that were not contractually due under this policy, then any benefits payable under this policy may be offset up to the amount of benefits you received that were not contractually due.
If you fail to cooperate with our investigation into the validity of your claim, benefits are not covered.
Benefits for a prosthetic device that replaces teeth that a Covered Person lost prior to the Effective Date are not covered, unless the device also replaces one or more natural teeth lost or extracted while covered under this policy.
Benefits for the replacement of congenitally missing teeth are not covered, unless you are replacing a current fixed bridge or denture. Such replacement is subject to policy replacement limits.
Benefits are not covered for:
- Any dental procedure or treatment not approved by the American Dental Association or which is clearly experimental in nature;
- Items, treatments, or services not listed in the Policy Schedule;
- Items, treatments, or services not prescribed by or performed under the direct supervision of a Dentist or Provider;
- Items, treatments, or services that are not Medically Necessary;
- Charges in excess of the Usual and Customary Charges;
- Treatment that results from participation in, or attempting to participate in, an illegal activity that is defined as a felony, whether charged or not (“felony” is as defined by the law of the jurisdiction in which the activity takes place); or being incarcerated in any detention facility or penal institution;
- Treatment resulting from an intentionally self-inflicted bodily injury, or committing or attempting suicide, while sane or insane;
- Cosmetic surgery or other elective procedures that are not Medically Necessary, except for reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection or other diseases;
- Orthodontic treatment; [implantology and related services; implants and all related procedures, including removal of implants;]
- Charges for any appliance or service that is used to change vertical dimension, restore or maintain occlusion, split or stabilize teeth for periodontal reasons, or treat disturbances of the temporomandibular joint (TMJ), unless mandated by state law;
- Charges for any service performed as a result of abrasion, attrition, bruxism, erosion, or abfraction;
- [Occlusal, athletic, or night guards;]
- Preventive root canal therapy;
- Full mouth debridement;
- Charges for any services that are considered to be an integral part of another service, such as pulp capping;
- Surgical trays, or sutures;
- Ridge preservation, augmentation, bone grafts, and regeneration procedures performed in edentulous sites;
- Overdentures or precision attachments;
- Space maintainers;
- Sealants for a Covered Person over the age of 16;
- Preparation and fitting of preformed dowel or post for root canal tooth; pulp cap either directly or indirectly;
- Duplicate or temporary devices, appliances, and services except as listed as a Covered Expense;
- Replacing a lost, stolen, or missing appliance or prosthetic device;
- Application of chemotherapeutic agents;
- Oral hygiene instruction, plaque control, diet instruction or infection control;
- Charges for sterilization of equipment, disposal of medical waste, or other requirements mandated by OSHA or other regulatory agencies;
- Treatment received while outside the territorial limits of the United States;
- Treatment of a condition that results from an on-the-job or job-related illness or injury;
- Treatment of a condition for which benefits are payable by Workers’ Compensation or similar laws, whether or not benefits are claimed;
- Treatment for which no charge is made or for which you are not legally obligated to pay, except Medicaid or similar state-sponsored programs;
- Telephone consultations and teledentistry;
- Charges for failure to keep a scheduled appointment, x-ray copy fees, or charges for completion of a claim form;
- Ancillary charges, including but not limited to, hospital, ambulatory surgical center or similar facility, or use of Provider office space;
- Impacted wisdom teeth;
- Prescription drugs;
- [Any surgical procedure performed in the treatment of cataracts;]
- Treatment that occurs while this policy is not in force.
Coverage is underwritten by Tier One Insurance Company.
Aflac’s family of insurers include Aflac, Aflac New York, Continental American Insurance Company, and Tier One Insurance Company.
Tier One Insurance Company is part of the Aflac family of insurers. In California, Tier One Insurance Company does business as Tier One Life Insurance Company (Tier One NAIC 92908).
Aflac WWHQ | Tier One Insurance Company | 1932 Wynnton Road | Columbus, GA 31999.