| Dental Rider |
Benefits |
CoPayments
/ Charges |
a)
Examinations |
No
charge |
b)
Diagnosis |
No
charge |
c)
Treatment Plans |
No
charge |
d)
Pulp Testing |
No
charge |
e)
Diagnostic Study Models |
No
charge
|
f)
Oral Cancer Examinations |
No
charge |
g)
Emergency Appointments |
$20
per visit |
a)
Complete Full mouth series (1 per yr) |
No
charge |
b)
Individual Peri-Apical Film |
No
charge |
c)
Additional Films |
No
charge |
d)
Bitewings / Bilateral |
No
charge |
a)
Complete Prophylaxis (2 per year) |
No
charge |
b)
Fluoride Treatments |
No
charge |
c)
Preventive Home Care Education |
No
charge |
d)
Oral Hygiene Instruction |
No
charge |
| e) Additional Prophylaxis | $30
per Quadrant |
| a) Amalgam / One surface | No
charge |
| b) Amalgam / Two surface | No
charge |
| c) Amalgam / Three surface | $20
per procedure |
| d) Silicates, Plastics, and Composites | No
charge |
| e) Pin Build-up | No
charge |
| f) Insulating Base | No
charge |
| g) Bonding / Ultraviolet Light | $30
per surface |
| a) Extraction / Uncomplicated | No
charge |
| b) Excision / Hyperplastic Tissue | No
charge |
| c) Dry Socket Treatment | No
charge |
| a) Anterior (front) tooth | $180
per procedure |
| b) Posterior / Two Canals | $225
per procedure |
| c) Posterior / Three Canals | $300
per procedure |
| d) Pupotomy - Pior to root canal | $100
per procedure |
| e) Post Care | $50
per procedure |
| a) Evaluation | No
charge |
| b) Curettage | $30
per Quadrant |
| c) Root Plane | $20
per Quadrant |
| d) Full Occlusal (bite) Adjust | $50
per procedure |
| e) Partial Occlusal Adjustment | No
charge |
| a) Broken Whole Mouth or lower acrylic excluding lab charges | No
charge |
| b) Cracked Full Upper or Lower acrylic excluding lab charges | No
charge |
| c) Repair or Replace Broken Tooth | $60
per tooth |
| d) Broken Clasp | $45
per Clasp |
| e) New additional Clasp | $45
per Clasp |
| f) Add Metal Strengthener | $60
per Procedure |
| g) Adjustment 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 |
| a) Temporary Acrylic Crown | No
charge |
| b) Full Cast / No Veneer | $110
per Procedure |
| c) Acrylic Veneer | $300
per Crown |
| d) Porcelain Over Metal | $300
per Crown |
| e) Porcelain Jacket Crown | $300
per Crown |
| f) Acrylic Jacket Crown | $200
per Crown |
| g) Metal or Acrylic Crown pre-fab | $80
per Crown |
| h) Replacement Old Bridge | No
charge |
| a) Complete upper or lower - Standard | $300
per device |
| b) Special cosmetic effects | No
charge |
| c) Immediate upper or lower - Full | $300
per device |
| d) Reline full upper or lower chairside | No
charge |
| e) Reline full upper or lower - Laboratory process | $75
per Procedure |
| f) Partial Upper or Lower - no metal Clasp | $180
per Procedure |
| g) Partial Upper or Lower - Acrylic Clasps | $300
per Procedure |
| h) Partial Upper or Lower - Cast base-Metal Clasp | $300
per Procedure |
| i) Partial upper or lower - Cast bar-Metal Clasps | $300
per Procedure |
| j) Full upper or lower metal strengthener | $75
per Procedure |
| k) Unilateral partial cast - Base clasps | $140
per Procedure |
| l) Soft tissue conditioner | No
charge |
| m) Night guard - Occlusal | $150
per Procedure |
| n) Adjustments | No
charge |
| a) Oral Surgery requiring the setting of fractures | |
| 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 Endorsment and if Coverage under this Endorsment is terminated or canceled for any reason whatsoever, said Member cannot reenroll for Coverage under this Endorsment. |
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