Dental
This option can be added to a medical plan. No employer contribution is required for the Dental Plan Option.
Dental Care Maximums
- $1500 annual maximum
- $500 periodontics maximum
- $750 orthodontics maximum
Dental Benefits: Scheduled amounts are payable up to $1,500 per covered person per calendar year for preventative and diagnostic care, restorative treatment, root canals, periodontics ($500 lifetime maximum), oral surgery and orthodontia ($750 maximum per course of treatment). Some benefits require a 12 month waiting period before benefits are available.
Survivor Benefit: Dependent coverage will continue, premium free, for up to 18 months after the end of the month in which the insured employee's death occurs.
Schedule of Benefits
|
Category |
Benefit Amount |
|
|
|
|
Type 1: Preventive & Diagnostic |
|
|
a) Oral exams, including prophylaxis |
$48.00 |
|
b) Bitewings, per film |
$6.40 |
|
c) X-ray, panoramic or cephalometric |
$48.00 |
|
d) Sealants / topical fluoride |
$13.60 |
|
e) Space maintainers |
$144.00 |
|
|
|
|
Type 2: Major Restorative |
|
|
a) Crowns, bridges & dentures |
$240.00 |
|
b) Pre-fabricated crowns |
$80.00 |
|
c) Crown build-up procedures |
$6400 |
|
|
|
|
Type 3: Minor Restorative |
|
|
a) Fillings |
$56.00 |
|
b) Crown, bridge and denture repairs |
$32.00 |
|
c) Relining or rebasing dentures |
$80.00 |
|
|
|
|
Type 4: Endodontics |
|
|
a) Root canals, apicoectomies |
$256.00 |
|
b) Root amputation |
$128.00 |
|
c) Therapeutic pulpotomy, retrograde fillings, apexification, hemisection |
$64.00 |
|
|
|
|
Type 5: Periodontics ($500 Lifetime Maximum) |
|
|
a) Tissue grafts or bone surgery |
$128.00 |
|
b) Gingivectomy (per quadrant), periodontal scaling, periodontal
periodontal scaling, periodontal splinting, root planing |
$80.00 |
|
c) Gingival curettage (per quadrant) |
$48.00 |
|
d) Gingivectomy (per tooth) |
$32.00 |
|
|
|
|
Type 6: Oral Surgery |
|
|
a) Surgeries Level 1 (ex. Removal of exostosis) |
$160.00 |
|
b) Surgeries Level 2 (ex. Removal of impacted tooth) |
$88.00 |
|
c) Surgeries Level 3 (ex. Simple extraction) |
$48.00 |
|
|
|
|
Type 7: General Anesthesia and IV |
|
|
a) IV, first half hour general, each additional 1/4 hour general |
$96.00 |
|
|
|
|
Type 8: Orthodontia (Per Course of Treatment) |
$750.00 |
|
|
|
|
Types 1 through 7 subject to annual maximum of: |
$1500.00 |
|
|
|
|
Types 2, 5, 6a, 7 and 8 are subject to 12 month waiting period |
|
Rates
|
Enrollees |
Monthly Rate |
| Employee |
$21.93 |
| Employee & Spouse |
$43.14 |
|
Employee & Child(ren) |
$57.90 |
| Family |
$79.11 |