1.
Diagnostic
|
| Type
of Benefits |
Co-Payments/Charges |
| (a)
Examination/evaluations |
No
Charge |
| (b
Pulp vitality tests |
No
Charge |
| (c)
Diagnostic Casts |
No
Charge |
[back to top]
|
2.
X-Rays |
| Type
of Benefits |
Co-Payments/Charges |
| (a)
Intraoral-complete series
(including bitewings)(1/member year) |
No
Charge |
| (b)
Intraoral-periapical first film |
No
Charge |
| (c)
Intraoral-periapical each additional film |
No
Charge |
| (d)
Bitewing single films |
No
Charge |
| (e)
Bitewings-2 films |
No
Charge |
| (f)
Bitewings-4 films |
No
Charge |
| (g)
Panoramic film (1/member/year) |
No
Charge |
[back to top]
|
3.
Preventive Care |
| Type
of Benefits |
Co-Payments/Charge |
| (a)
Complete Prophylaxis-adult
Two per Member per Calendar Year |
No
Charge |
|
(b)
Complete Prophylaxis-adult (additional) |
$30 |
| (c)
Complete Prophylaxis-child
Two per Member per Calendar Year |
No
Charge |
|
(d)
Complete Prophylaxis-child (additional) |
$30 |
| (e)
Fluoride Treatment-child (prophylaxis
not included) |
No
Charge |
| (f)
Fluoride Treatment-adult (prophylaxis
not included) |
No
Charge |
| (g)
Oral Hygiene Instruction |
No
Charge |
[back to top]
|
4.
Restorative(Fillings) |
| Type
of Benefits |
Co-Payments/Charges |
| (a)
Amalgam/One Surface (primary/permanent) |
No
Charge |
| (b)
Amalgam/Two Surface (primary/permanent) |
No
Charge |
| (c)
Amalgam/Three Surface (primary/permanent) |
$20 |
| (d)
Resin-based composite--one surface, anterior |
$30 |
| (e)
Resin-based composite--two surfaces, anterior
|
$60 |
| (f)
Resin-based composite--three surfaces,
anterior |
$90 |
| (g)
Resin-based composite--four or more surfaces,
anterior |
$120 |
| (h)
Pin retention (per tooth, in addition
to restoration) |
No
Charge |
[back to top]
|
5.
Fixed Crown and Bridge |
| Type
of Benefits |
Co-Payments/Charges |
| (a)
Crown--resin (indirect) |
$200
per Crown |
| (b)
Crown--resin with high noble metal |
$450
per Crown |
| (c)
Crown--resin with predominantly base metal |
$300
per Crown |
| (d)
Crown--resin with noble metal |
$400
per Crown |
| (e)
Crown--porcelain fused to high noble metal |
$450
per Crown |
| (f)
Crown--porcelain fused to predominantly
base metal |
$300
per Crown |
| (g)
Crown--porcelain fused to noble metal |
$400
per Crown |
| (h)
Crown--full cast high noble metal |
$450
per Crown |
| (i)
Crown--full cast predominantly base metal |
$300
per Crown |
| (j)
Crown--full cast noble metal |
$400
per Crown |
| (k)
Prefabricated stainless steel crown (primary
tooth) |
$80
per Crown |
| (l)
Prefabricated stainless steel crown (permanent
tooth) |
$80
per Crown |
| (m)
Prefabricated resin crown |
$80
per Crown |
| (n)
Crown repair, by report |
$40
per Crown |
| (o)
Pontic--cast high nobel metal |
$450 |
| (p)
Pontic--cast predominantly base metal |
$300 |
| (q)
Pontic--cast nobel metal |
$400 |
| (r)
Pontic--porcelain fused to high noble
metal |
$450 |
| (s)
Pontic--porcelain fused to predominantly
base metal |
$300 |
| (t)
Pontic--porcelain fused to noble metal |
$400 |
| (u)
Pontic--resin with high noble metal |
$450 |
| (v)
Pontic--resin with predominantly base
metal |
$300 |
| (w)
Pontic--resin with noble metal |
$400 |
| (x)
Crown--resin with high noble metal |
$450
per Crown |
| (y)
Crown--resin with predominantly base metal |
$300
per Crown |
| (z)
Crown--resin with noble metal |
$400
per Crown |
| Recement
fixed partial denture |
No
Charge |
[back to top]
|
6.
Endodontics (Root Canal Therapy) |
| Type
of Benefits |
Co-Payments/Charges |
| (a)
Therapeutic pulpotomy |
$100 |
| (a)
Anterior root canal (excluding final restoration) |
$180
per Procedure |
| (b)
Biscuspid root canal (excluding final
restoration) |
$225
per Procedure |
| (c)
Molar root canal (excluding final restoration) |
$300
per Procedure |
| (d)
Post Care |
$50
per Procedure |
[back to top]
|
7.
Periodontics (Gum Treatment) |
| Type
of Benefits |
Co-Payments/Charges |
| (a)
Evaluation |
No
Charge |
| (b)
Periodontal scaling and root planing (per
quadrant) |
$20
per Quadrant |
| (c)
Occlusal (bite) adjustment (complete) |
$50
Per Procedure |
| (d)
Occlusal (bite) adjustment (limited) |
No
Charge |
[back to top]
|
8.
Prosthetics (Full and Partial Dentures) |
| Type
of Benefits |
Co-Payments/Charges |
| (a)
Complete denture--maxillary |
$300 |
| (b)
Complete denture--mandibular |
$300 |
| (c)
Immediate denture--maxillary |
$300 |
| (d)
Immediate denture--mandibular |
$300 |
| (e)
Mandibular partial denture--resin base
(including any conventional clasps, rests
and teeth) |
$300 |
| (f)
Maxillary partial denture--resin base
(including any conventional clasps, rests
and teeth) |
$300 |
| (g)
Maxillary partial denture--cast metal
framework with resin denture bases (including
any conventional clasps, rests and teeth) |
$300 |
| (h)
Mandibular partial denture--cast metal
framework with resin denture bases (including
any conventional clasps, rests and teeth) |
$300 |
| (i)
Removable unilateral partial denture-one
piece cast metal (including clasps and
teeth) |
$140 |
| (j)
Adjust complete denture--maxillary |
No
Charge |
| (k)
Adjust complete denture--mandibular |
No
Charge |
| (l)
Adjust partial denture--maxillary |
No
Charge |
| (m)
Adjust partial denture--mandibular |
No
Charge |
| (n)
Reline complete maxillary denture (chairside) |
No
Charge |
| (o)
Reline complete mandibular denture (chairside) |
No
Charge |
| (p)
Reline complete maxillary denture (laboratoty) |
$75 |
| (q)
Reline complete mandibular denture (laboratoty) |
$75 |
| (r)
Tissue conditioning, maxillary |
No
Charge |
| (s)
Tissue conditioning, mandibular |
No
Charge |
| (s)
Occlusal guard, by report |
$150 |
[back to top]
|
9.
Repairs to Prosthetics
(Full & Partial Dentures) |
| Type
of Benefits |
Co-Payments/Charges |
|
(a)
Repair broken complete denture base
EXCLUDING lab charges |
No
Charge |
| (b)
Replace missing or broken teeth--complete
denture (each tooth) |
$60 |
| (c)
Repair resin denture base
EXCLUDING lab charges |
No
Charge |
| (d)
Repair or replace broken clasp |
$45
per clasp |
| (e)
Replace broken teeth--per tooth |
$60 |
| (f)
Add clasp to existing partial denture |
$45 |
| (g)
Adjustments to Repairs |
No
Charge |
| (h)
Repair or Reset Metal Bar |
$45
per Procedure |
| (i)
Reset anterior (front) teeth |
$60
per Procedure |
| (j)
Repair Facing |
$40
per Procedure |
[back to top]
|
10.
Oral Surgery |
| Type
of Benefits |
Co-Payments/Charges |
| (a)
Coronal remnants-deciduos tooth |
No
Charge |
| (b)
Extraction, erupted tooth or exposed root |
No
Charge |
| (c)
Excision of hyperplastic tissue (per ach) |
No
Charge |
[back to top]
|
11.
Appointments |
| Type
of Benefits |
Co-Payments/Charges |
| (a)
Emergency appointment |
$20 |
[back to top]
12.
Specialist Care
Should you need a specialist
(i.e.,Endodontist,Orthodontist,Oral Surgeon,Periodontist,Prosthodontist,Pediatric
Dentist), you may be referred by our Participating
General Dentist, or you may refer yourself to
any participating specialist. Upon identification
of yourself as a member of this dental plan,
you will receive a 25% reduction from usual
and customary fees for services performed. Specialist
services are available only in areas where the
dental plan has a participating specialist.
NOTE: Cosmetic
procedures and procedures not listed on the
Benefits Schedule will be provided at the participating
dentist's usual,customary and reasonable (UCR)
fees less 25%.
[back to top]
|
The following limitations
and exclusions apply to the dental services listed
above:
(a) Oral surgery requiring
the setting of fractures or dislocation.
(b) Care for congenital malformation.
(c) Care for malignancies.
(d) Drugs not normally supplied in a dental office.
(e) Care that cannot be provided in the dental office.
(f) Care, which cannot be provided due to the general
health or physical limitations of the Member.
(g) Care which, in the opinion of Health Plan, is
not Medically Necessary for maintaining the Member
dental health.
(h) Precision attachments and stress breakers.
(i) Replacement of partial or full dentures within
two (2) years after installation unless the need for
replacement results from the acts or omissions of
Health Plan.
(j) Care considered by Health Plan to be experimental.
(k) Care requiring the admissions of general anesthetic.
(l) Care that is not arranged for by Health Plan or
care provided by a no-contracted dentist.
(m) Care required primarily for cosmetic purposes,
including complications therefrom.
(n) Implantation procedures.
(o) Extraction of impacted wisdom teeth.
(p) Apiceptomy.
(q) Services that are not specifically set forth in
Section 2.2 hereof as Covered Services.
A member can only enroll
for Coverage under this Plan once per lifetime, If
a Member is enrolled for Coverage under this Plan
and if Coverage under this Plan is terminated or canceled
for any reason whatsoever, said Member cannot reenroll
for Coverage under this Plan.
More Options :
The Vision Plan is available for subscribers, for a $5.00 additional premium. This vision/optical plan is designed to provide coverage for medically necessary visual needs, and does not provide benefits for cosmetic or aesthetic purposes.