Plan Summaries
Summary of Benefits for Plan 4
Comprehensive Plus
DIAGNOSTIC - 100%- Oral Examinations
- Office Visits
- Diagnostic Casts
- Dental X-Rays
- Professional Consultation
- Plaque Control, Oral Hygiene Instructions
- Prophylaxis (Cleaning; Once in a Six-Month Period)
- Preventive Dental Hygiene
- Topical Applications of Fluoride (Up to Age 14)
- Sealants (Up to Age 14 on Permanent Molars Only)
- Amalgam Restorations (for Treatment of Cavities)
- Composite Restorations on Anterior Teeth
- Composite Restorations on Posterior Teeth (For Treatment of Cavities)*
- Pulpotomy (on Primary Teeth Only)
- Pin Retention
- Space Maintainers to replace prematurely lost teeth
- Local Anesthesia
- Simple Extraction of erupted tooth
- Surgical Extraction of erupted tooth
- Root Canal Treatment (Anterior and Bicuspid Teeth Only)
- Pulpotomy (Permanent Teeth)
- Root Canal Treatment (Molar Teeth Only)
- Periodontal Scaling
- Root Planing
- Inlays, Onlays, Crowns
- Bridges
- Dentures
- Services provided by a non-participating DDS out of geographic service area - up to $25
- Treatments for Tooth Guidance/Control of Harmful Habits, Interceptive Orthodontic Treatment and Treatment for Transitional and Permanent Dentition
ANNUAL NON-ORTHODONTIC MAXIMUM - $1200
*Will not duplicate surgical/medical benefits.
**Noble, if used, will be charged to the patient at the dentist's cost.
***Age 18 and under only. ADP covers 50% up to
a maximum benefit
of
$1000.00/person. This
is a lifetime benefit.