Allegiance Plan
Underwritten by The United States Life Insurance Company in the City of New York, a member company of American International Group, Inc. and rated A++ by A.M. Best.

  PLAN PROVISIONS
Group Size: 2 + employees
Plan Type: PPO
Calendar Year Deductible: $50 all services.
Calendar Year Maximum: $1000 or $1500 maximum per calendar year.
Waiting Period: 12 months on Major; 12 months on Orthodontia
Waiting Period Waiver (Optional): 5% Load – Takeover groups only.
Orthodontia (Optional): $1000 Lifetime maximum per person ($1500 on groups 51 or more). Child Only or Full Family Coverage available (children to age 19, students to age 25).
Effective Date: 1st or 15th of the month.
Initial Rate Guarantee: 12 months (24 months optional – 5% load).

  UNDERWRITING / ELIGIBILITY
Minimum Contribution: 35% of employee premium or 25% of employee and dependent premium
Minimum Participation: Non-contributory: 100% of all eligible employees;
Contributory: 2-5 employees 100%; 6-8 employees all but 1; 9 or more employees 75% required.
Administrator: AmeriSecure Division/Insurers Administrative Corporation (IAC).
Additional Fees: $15 per month.
Enrollment Requirements: First month’s premium check payable to AmeriSecure; Group App; employee apps/waivers; State Wage and Tax Summary; prior carrier bill/cert. if replacement.
Subject to Administrator: 10 days prior to requested effective date.
  BENEFIT SUMMARY
  IN NETWORK OUT OF NETWORK*
  Preventative Services
  Exams
  X-rays
  Sealants
  Cleaning
  Fluoride Treatment		 100% 100%
  Basic Services
  Fillings
  Simple Extractions
  Oral Surgery
  Recementing
  Repair to Full and Partial Dentures		 80% 80%
  Major Services
  Root Canals**
  Endodontics, Periodontics**
  Restorative Services
  Prosthetic Services
50%		 50%
  Optional Orthodontic Services
(Child Only or Full Family) 		50% 50%



*Out of Network reimbursements are based on the negotiated PPO contract.
**Option: Endodontics & Periodontics may be considered as Basic Services for groups of 10 or more enrolling employees.

This is a brief description of coverage provided under policy form series G-19000 and is subject to the terms, limitations, and exclusions of the group policy. Please see the certificate for details.

This information is intended as a summary only. Benefits may be subject to limitations and exclusions. This does not replace the master policy or the plan brochure. It is as accurate as possible, but we cannot be responsible for errors and make no warranty of any kind. For full details, refer to certificate of coverage.