Plan Summaries
Summary of Benefits
Alliance Chamber Health Insurance Program - Plan C
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)*
- 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)
- Root Canal Treatment (Molar Teeth Only)
- Periodontal Scaling
- Root Planing
- Inlays, Onlays, Crowns
- Bridges
- Dentures
- Services provided by a non-participating DDS Up to $25 out of geographic service area
ANNUAL NON-ORTHODONTIC MAXIMUM - $1200
*Benefit applied at 100% of the amalgam fee for same restoration.
Patient is responsible for the difference.
**Will not duplicate surgical/medical benefits of a plan sponsored
by the same employer.