Dental, Vision and

Hearing Select

This is a Limited Benefit Insurance Policy for Dental, Vision and

Hearing Expenses.
Underwritten by ManhattanLife Insurance and Annuity Company

DVHS-PABR 0223
 The Importance of Dental | Vision | Hearing
• Help maintain quality of life
• Financial protection in unforeseen situations that are painful, inconvenient, and expensive
• Basic Medicare does not cover dental, vision or hearing expenses

PRODUCTS HIGHLIGHTS
• Individual ages 18 – 99 • $1,000, $1,500, $3,000, or $5,000 policy year
• Family rates (include up to 3 children) maximum benefit
• $0 or $100 deductible • Orthodontia benefit
(does not apply to Preventive Services) • No waiting periods for Dental Services
• Glasses, Contacts and Hearing Aid benefits (except Orthodontia)
• Guaranteed renewable for life* • Guaranteed issue
• Choose your dentist (in-network or out-of-network) * Subject to our right to change premiums.

Flexibility to choose . . .

+ + + +

Dental Only Dental and Vision Dental and Hearing Dental, Vision and Hearing

Dental, Vision and Hearing Select from ManhattanLife was designed with you in mind. With the ability to choose
specific benefits, you can customize a plan tailored to fit your needs.

26% of adults in the United States have untreated tooth decay. 1

46% of adults aged 30 years or older show signs of gum disease. 2

1
Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United
States, 1999–2004 to 2011–2016. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2019.
2
Eke P, Thornton-Evans G, Wei L, Borgnakke W, Dye B, Genco R. Periodontitis in US adults: National Health and Nutrition Examination Survey 2009-
2014. JADA. 2018;149(7):576-586.
 Plan Eligibility: Ages 18 - 99
Policy Year Maximum Benefit: $1,000, $1,500, $3,000 or $5,000
Benefits Policy Year Deductible: $0 or $100 per person (does not apply to Preventative Services)

In-Network Out-of-Network
Preventive Services
• Dental Exams; 2 per year • Bitewing X-Rays; 2 per year 100% of
80% of UCR
• Cleanings; 2 per year • Fluoride treatment is for age 16 contracted rate
and under; 2 visits per year
Basic Services
• Limited Oral Evaluation • Basic Restorative Service
• Diagnostic Consultation • Filling 65% of contracted
65% of UCR 1st yr.
• Emergency Palliative Treatment • Basic Oral Surgery rate 1st yr.
Dental Coverage

80% thereafter
• Panoramic X-Ray • Periodontal Service 80% thereafter
• Periapical X-Ray • Non-Surgical Extraction
• Periodontal Non-Surgical Service
Major Services
20% of contracted
• Major Restorative Service • Periodontal Service 20% of UCR 1st yr.
rate 1st yr.
• Inlay/Onlay/Crown • Prosthodontic Service 50% thereafter
50% thereafter
• Endodontic Service • Implants 2
20% of contracted
All Other Medically Necessary Services 20% of UCR 1st yr.
rate 1st yr.
(services not listed above) 50% thereafter
50% thereafter
Orthodontia 1
Year 1 - N/A
• Straightening of teeth (for all ages) N/A
Year 2+ - 50%
• Lifetime max $1,500 2

Vision Services 60% of UCR 1st yr.

• Eye Exam • Refraction 70% of UCR 2nd yr.
Vision Rider

• Single Lenses • Bifocal Lenses 80% of UCR thereafter

• Trifocal Lenses • Progressive Lenses 1 per year
• Eyeglass Frame 3
• Contact Lenses $200 maximum per year
• Anti-Reflective Lenses $45; 1 per year
• Polycarbonate Lenses $40; 1 per year
• Contact Lens Fitting Fee $15; 1 per year

Hearing Services
Hearing Rider

• Hearing Exam • Hearing Aid and Necessary

Repairs or Supplies 1 $750 maximum
(per ear, per year)

1
12 Month Waiting Period; 2
Lifetime Maximum $1,500; 3
6 Month Waiting Period
We continue our history of “Standing By You” through our partnership with Careington Maximum
Care PPO Dental Network. Our partnership provides policyholders access to discounted costs on
a wide range of services.

CAREINGTON NETWORK*
Clients can access the Careington Maximum Care PPO Dental Network. Use of network is
completely optional.
• Policyholders can benefit from choosing a dental provider from the Careington Dental Network.
• Policyholders can also use the dentist of their choice, even if they are not part of the dental
network.
• Network discounts may help extend the policy year maximum with reduced charges.
• Careington can be contacted at (800) 290-0523.

Discounted fees to help your Access to quality dentists all 100,000+

dental benefits go further around the country Dentists Nationwide

So while you can choose your own dentist, visiting a Careington dental network provider offers
greater savings and discounts. Visit https://manhattanlife.solutionssimplified.com/ to find a
Careington dentist near you.

*Careington was founded in 1979 by two dentists and is rated A+ with the Better Business Bureau (BBB).
Understanding How Your Benefits Work
In-Network
Peter goes to his Careington Network dentist for a regular check-up. Upon examination, the dentist realizes that Peter
needs a filling. Luckily, Peter has a Dental Plan with ManhattanLife. He has met his $100 annual deductible.
Procedure: Provider Charge In-Network Cost ManhattanLife Pays You Pay
100% Preventative day one;
Dental Exam $150 $35 $0
$35.00
65% Basic day one; $35
Filling $275 $99
Dental Coverage

(of In-Network Cost = $64) ($99 - $64)

Total $425 $134 $99 $35

Out-of-Network
Peter chose not to use the Careington Network and instead goes to an out-of-network dentist for a regular check-
up. Upon examination, the dentist realizes that he needs a filling. Peter has a Dental Plan with ManhattanLife. He
has met his $100 annual deductible.
Procedure: Provider Charge Out-of-Network Cost* ManhattanLife Pays You Pay
80% Preventative day one; $73
Dental Exam $150 $96
(of Usual and Customary = $77) ($150 - $77)

65% Basic day one; $111

Filling $225 $175
(of Usual and Customary = $114) ($225 - $114)

Total $375 $271 $191 $184

*subject to the Usual and Customary charges based in zip code 77092

Earl goes to the Eye Doctor for an eye exam and gets glasses. He has had a Dental + Vision plan with
ManhattanLife for over a year and has met his annual deductible.
Procedure:* Cost ManhattanLife Pays You Pay
Vision Rider

70% year two

Eye exam $60 $18
$42
$200 maximum;
Eyeglass Frame $250 $50
$200
70% year two
Lenses $115 $34
$81
Total $425 $323 $102
*subject to the Usual and Customary charges based in zip code 77092

After a 12 month waiting period Brian decides to get his hearing checked, as he’s noticed a progressive hearing
decline. His ENT specialist recommends Brian get hearing aids to help relieve the hearing loss. Utilizing the hearing
portion of the plan, his exam and devices would have been covered as follows:
Hearing Rider

Procedure:* Cost ManhattanLife Pays You Pay

Hearing Exam $90 $750 maximum per ear, per year: $90 $0
$750 maximum per ear, per year:
Hearing Aids $1,600 $190
$1,500 - $90 (Hearing Exam) = $1,410
Total $1,690 $1,500 $190
*subject to the Usual and Customary charges based in zip code 77092

*For illustrative purposes only. Claims examples are subject to geographic region, out of network provider and usual & customary charges.
 Dental, Vision & Hearing Select Monthly Rates*
DENTAL COVERAGE
$1,000 Maximum Benefit
$0 Deductible $100 Deductible
Individual + Individual + Individual + Individual +
Age Individual Family Age Individual Family
Spouse Child(ren) Spouse Child(ren)
3 - 17 $31.11 3 - 17 $28.58
18 - 39 $33.53 $67.07 $80.21 $121.52 18 - 39 $29.83 $59.67 $72.70 $109.68
40 - 54 $42.76 $85.53 $117.87 $144.64 40 - 54 $38.28 $76.56 $106.68 $130.86
55 - 64 $45.57 $91.14 $109.42 $133.14 55 - 64 $41.05 $82.11 $99.20 $120.69
65 - 74 $48.06 $96.11 $94.78 $111.67 65 - 74 $43.41 $86.82 $85.73 $101.11
75 - 99 $51.24 $102.48 $97.44 $110.26 75 - 99 $46.06 $92.12 $87.68 $99.27

$1,500 Maximum Benefit

$0 Deductible $100 Deductible
Individual + Individual + Individual + Individual +
Age Individual Family Age Individual Family
Spouse Child(ren) Spouse Child(ren)
3 - 17 $33.11 3 - 17 $30.56
18 - 39 $35.65 $71.31 $85.32 $129.25 18 - 39 $31.81 $63.62 $77.65 $117.10
40 - 54 $45.63 $91.25 $125.62 $154.16 40 - 54 $40.96 $81.92 $114.11 $139.98
55 - 64 $48.76 $97.51 $116.86 $142.21 55 - 64 $44.04 $88.09 $106.31 $129.34
65 - 74 $51.60 $103.21 $101.70 $119.76 65 - 74 $46.74 $93.48 $92.26 $108.76
75 - 99 $55.23 $110.46 $104.96 $118.74 75 - 99 $49.81 $99.61 $94.75 $107.25

$3,000 Maximum Benefit

$0 Deductible $100 Deductible
Individual + Individual + Individual + Individual +
Age Individual Family Age Individual Family
Spouse Child(ren) Spouse Child(ren)
3 - 17 $38.78 3 - 17 $35.52
18 - 39 $40.09 $80.18 $98.27 $148.05 18 - 39 $35.91 $71.82 $89.20 $133.99
40 - 54 $51.67 $103.34 $144.33 $177.03 40 - 54 $46.57 $93.14 $130.99 $160.64
55 - 64 $55.54 $111.07 $134.34 $163.43 55 - 64 $50.36 $100.72 $122.23 $148.68
65 - 74 $59.16 $118.31 $116.80 $137.71 65 - 74 $53.79 $107.59 $106.27 $125.35
75 - 99 $63.65 $127.30 $121.05 $137.00 75 - 99 $57.66 $115.32 $109.72 $124.20

$5,000 Maximum Benefit

$0 Deductible $100 Deductible
Individual + Individual + Individual + Individual +
Age Individual Family Age Individual Family
Spouse Child(ren) Spouse Child(ren)
3 - 17 $43.18 3 - 17 $38.30
18 - 39 $43.85 $87.71 $108.62 $163.27 18 - 39 $39.33 $78.65 $96.78 $145.68
40 - 54 $56.69 $113.39 $159.36 $195.43 40 - 54 $51.16 $102.32 $142.74 $175.10
55 - 64 $61.09 $122.17 $148.36 $180.46 55 - 64 $55.46 $110.91 $133.66 $162.63
65 - 74 $65.23 $130.46 $128.89 $152.05 65 - 74 $59.39 $118.78 $117.09 $137.94
75 - 99 $70.30 $140.59 $133.74 $151.39 75 - 99 $63.77 $127.54 $121.20 $137.12
* Pricing based off Issue Age

Both “Individual + Child(ren)” and “Family” rates include up to three children. Additional children are charged the age 3-17 rate per person. Premiums are
subject to change. Premium rates based on $1,000, $1,500, $3,000 or $5,000 Policy Year Maximum. Rate based off the age of the eldest/oldest applicant.
Benefit exclusions and limitations apply.
 VISION RIDER
Age Individual Individual + Spouse Individual + Child(ren) Family

3 - 17 $2.99

18 - 39 $3.81 $7.61 $9.50 $14.50

40 - 54 $8.16 $16.31 $13.25 $22.48

55 - 64 $8.70 $17.40 $12.89 $22.48

65 - 74 $10.15 $20.30 $11.35 $21.75

75 - 99 $10.15 $20.30 $11.35 $21.75

HEARING RIDER
Age Individual Individual + Spouse Individual + Child(ren) Family

3 - 17 $1.01

18 - 39 $0.67 $1.33 $2.59 $3.67

40 - 54 $1.33 $2.67 $3.47 $5.25

55 - 64 $2.50 $5.00 $3.88 $6.67

65 - 74 $3.50 $7.00 $3.91 $7.50

75 - 99 $4.17 $8.33 $3.82 $7.92

Both “Individual + Child(ren)” and “Family” rates include up to three children. Additional children are charged the age 3-17 rate per person.
Premiums are subject to change. Premium rates based on $1,000, $1,500, $3,000 or $5,000 Policy Year Maximum. Rate based off the age
of the eldest/oldest applicant. Benefit exclusions and limitations apply.
 Underwritten by:
ManhattanLife Insurance and Annuity Company
Administrative Office: 10777 Northwest Freeway, Houston, TX 77092
Toll Free Telephone: 800-669-9030

This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for
the Dental, Vision and Hearing product at disclosure.manhattanlife.com. Please review this information before applying for
coverage. The amounts of benefits provided depend on the plan selected. Premiums will vary according to the selection made.
Policy Form Numbers: AK7034-PA
Rider Form Numbers: AK7034HR, AK7034VR