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Schedule of Benefits for Dental Plans
What the dental plan will pay - Over 250 Covered Procedures
|Sample Schedule of Benefits - How much the insurance will pay||Low Plan||High Plan|
|Plan Maximum Per Calendar Year-Per Person||$1000||$1000|
|Dental Deductible - Basic and Major Services Only||$50||$50|
|Preventive* - NO DEDUCTIBLE||100%||100%|
|Two routine exams per calendar year||100%|
|Two cleanings per calendar year||100%|
|Fluoride for Children, under age 19 (1 per Calendar Year)||100%|
|Full Mouth/Panoramic X-rays (1 in 3 years)||100%|
|Bitewings (Allowed twice per calendar year)||100%|
|Sealant-per tooth (Coverage is limited to treatment of the occlusal surface of permanent molar teeth once during a 3-year period) (Age 16 and under)||$18|
|Amalgam restoration (silver fillings)—one surface, primary or permanent||$41|
|Extraction—Erupted tooth or exposed root (elevation and/or forceps removal)||$46|
|Surgical removal of tooth (completely bony)||$171|
|Denture repair-Repair Broken Base||$52|
|Deep sedation/general anesthesia||$131|
|Major - 12 mo. waiting period||Scheduled||50%|
|Maxillary partial denture—resin base||$135|
|Endodontics—root canal, anterior||$105|
|Periodontal scaling and root planning, limited (per quadrant). Each quadrant is eligible for consideration once in a 2 year period||$35|
|Crown—full cast noble metal||$152|
|Pontics—porcelain fused to noble metal||$156|
* Preventive benefits are paid at 100% of the average charge in your zip codes area
Covered Expenses will not include and no benefit will be payable for expenses incurred:
- For any procedures except exams, cleaning and flouride applications for the first 12 months when an employee or dependent becomes classified as a late entrant. An employee or dependent who does not enroll within 31 days from the date the person qualifies for the insurance, or who elects to become covered again after canceling a premium contribution agreement, will be classified as a late entrant.
- For any treatment which is for cosmetic purposes, except as specifically listed in the Table of Dental Procedures.
- For initial placement of any dental prosthesis or prosthetic crown unless such placement is needed because of the extraction of one or more teeth while the plan member is covered under the dental expense benefit. The extraction of a third molar (wisdom tooth) will not qualify under the above. Any such dental prosthesis or prosthetic crown must include the replacement of the extracted tooth or teeth.
- For any procedure begun before the plan member was covered under the dental expense benefit.
- For any procedure began after the member's insurance under the dental expense benefit terminates; or for any prosthetic dental appliance installed or delivered more than 90 days after the member's insurance under the dental expense benefit terminates.
- To replace lost or stolen appliances.
- For appliances, restorations, or procedures to:
- a. alter vertical dimension;
- b. restore or maintain occlusion;
- c. splint or replace tooth structure lost because of abrasion or attrition
- For any procedure which is not shown on the Table of Dental Procedures.
- For orthodontic treatment (unless otherwise specified in this contract).
- For which the plan member is entitled to benefits under any workmen's compensation or similar law, or changes for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course on any employment for wage or profit.
- For charges for which the plan member is not liable or which would not have been made had no insurance been in force.
- For services which are not required for necessary care and treatment or are not within the generally accepted parameters of care.
- Because of war or any act of war, declared or not.
- To replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed partial denture within five years of the date of the last placement of these terms. However, if a replacement is required because of an accidental bodily injury sustained while the plan member is covered under the dental expense benefit, it will be a Cover Expense.