Dental Rider
Benefits
CoPayments / Charges
1. Diagnostic
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
2. X-Rays
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
3. Preventive Care
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
4. Fillings / Restorative
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
5. Oral Surgery
a) Extraction / Uncomplicated
No charge
b) Excision / Hyperplastic Tissue
No charge
c) Dry Socket Treatment
No charge
6. Root Canal / Endodontics
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
7. Soft Tissue / Periodontics
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
8. Repairs
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
9. Fixed Crown and Bridge
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
10. Prosthetics
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
11. Limitations and Exclusions
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.