Dental Care Plan

Copayment

$15 copayment per examination-100% of maximum allowable charge

Benefits

• Two routine periodic examinations in any 12-month period.
• Bitewing X-rays once in every 12-month period.
• Full mouth X-rays once in any 36-month period.
• Topical fluoride application for members under age 19, once in any 12-month interval.
• Prophylaxis and periodontal maintenance, not to exceed 2 per year.
• Any combination of exams -- initial, periodic emergency or periodontal -- limited to 3 times in a 12-month period.

Copayment

$15 copayment for each of the following services – 100% of the maximum allowable charge

Benefits

• Sealants, only for occlusal (biting) surface of first and second permanent molar teeth on members under 16 years of age. Only 1 sealant benefit will be allowed on each tooth per lifetime of coverage. The copayment applies per tooth for this service.

Copayment

$25 copayment for each of the following services – 100% of the maximum allowable charge

Benefits

• Emergency treatment for relief of pain.
• Restorative services: filling material such as amalgam, synthetic porcelain and composite restorations--limited to 1 restoration per surface per tooth per year. The copayment applies per tooth for this service.
• Oral surgery: provides for routine extractions (non-impacted), including pre- and post-operative care. The copayment applies per tooth for this service.
• Repair of full and partial dentures after 12 month initial placement. The copayment applies per procedure – upper and lower dentures are considered separate procedures.
• Stainless steel crowns. The copayment applies per tooth for this service.
• Bridge repair after 6-month initial placement. The copayment applies per procedure.
• Crown repair after 6-month initial placement. The copayment applies per procedure.

Copayment

$75 copayment for each of the following services - 100% of the maximum allowable charge

Benefits

• Endodontics: root canal treatment. The copayment applies per tooth for this service.
• Periodontics: treatment for diseases of the gums and bones supporting teeth. The copayment applies per procedure.
• Surgical extractions (impactions). The copayment applies per tooth.
• Space maintainers for members up to age 14. The copayment applies per procedure.
• Relining and rebasing of full and partial dentures limited to 1 upper and 1 lower every 3 years. Separate copayments for upper and lower.

Copayment

$75 copayment for each of the following services - 50% of the maximum allowable charge

Benefits

• Full and partial upper and lower dentures. Separate copayments for upper and lower.
• Benefits will be provided for any necessary adjustments for a 6-month period.
• Initial placement of fixed and removable bridges by standard procedure. The copayment applies per tooth.
• Cast crowns for treatment of severe carious lesions or severe fracture when the tooth cannot be restored with amalgam, synthetic porcelain or composite restorations. The copayment applies per tooth.
• Cast inlays/onlays (copayment per tooth).
• Laminate veneers (copayment per tooth).

Copayment

$1,500 per member