The following is a summary of the standard prepaid dental plans available for Voluntary Groups of less than 50 members. The following is a summary of the covered benefits, copayments (member cost) and monthly rates for services provided by a participating general dentist:
|
Member Co-payments |
| Prepaid Plans |
Plan
465 |
Plan
595 |
Plan
495 |
| Annual Deductibles |
None |
None |
None |
| Annual Maximums |
None |
None |
None |
| Preventative
Services |
| Exam, X-rays &
Cleanings |
No Charge |
No Charge |
No Charge |
| Routine
Services |
|
|
|
| Amalgam Fillings |
|
|
|
|
One Surface |
$10.00 |
$4.00 |
$2.00 |
|
Two Surface |
$15.00 |
$5.00 |
$3.00 |
| Resin Filling, One Surface |
$25.00 |
$14.00 |
$10.00 |
| Simple Extraction |
$25.00 |
$10.00 |
$5.00 |
| Surgical Extraction |
|
|
|
|
Tissue Impacted |
$60.00 |
$40.00 |
$30.00 |
| Root Canal, Anterior Teeth |
$125.00 |
$80.00 |
$45.00 |
| Major
Services |
|
|
|
| Resin Crown, Laboratory |
$145.00 |
$105.00 |
105.00 |
| Porcelain Crown (PFM) |
$275.00 |
$156.00 |
$105.00 |
| PFM for Molars |
$350.00 |
$236.00 |
$185.00 |
| Complete Denture |
$350.00 |
$160.00 |
$90.00 |
| Partial Denture |
$350.00 |
$175.00 |
$90.00 |
| Orthodontics |
|
|
|
| Upper & Lower, Standard
24-Month Case |
|
|
|
| Children to age 18 |
$1,775.00 |
$1,695.00 |
$1,695.00 |
| Adults |
$1,995.00 |
$1,695.00 |
$1,695.00 |
| Monthly
Rates |
| Single |
$7.95 |
$10.95 |
$14.50 |
| Couple |
$11.95 |
$18.95 |
$26.95 |
| Family |
$16.95 |
$28.95 |
$39.95 |
Coverage includes specialty referral benefits at 25% the first year and 50% the second and subsequent years, of the participating dental specialist's usual, customary and reasonable fee, up to a $1,000 a year in services. Members enrolling on the group's effective date will receive credit for prior coverage, for specialty referral benefits.
Other services are covered with comparable savings. For a complete list of covered services view the schedule of benefits for the plan of your choice.
|
