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
 PREVENTIVE - 100%
  • 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)
 RESTORATIVE - 100%
  • 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
 ORAL SURGERY - 80%**
  • Simple Extraction of erupted tooth
  • Surgical Extraction of erupted tooth
 ENDODONTICS - 80%
  • Root Canal Treatment (Anterior and Bicuspid Teeth Only)
 ENDODONTICS - 50%
  • Root Canal Treatment (Molar Teeth Only)
 PERIODONTICS - 80%
  • Periodontal Scaling
  • Root Planing
 MAJOR RESTORATIVE - 50%
  • Inlays, Onlays, Crowns
 PROSTHODONTICS - 50%
  • Bridges
  • Dentures
 OUT-OF-AREA EMERGENCY - up to $25

  • Services provided by a non-participating DDS Up to $25 out of geographic service area

 ORTHODONTICS - Up to 50%***

  • Treatment for tooth guidance, control of harmful habits, interceptive orthodontic treatment and treatment for transitional and permanent dentition.

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.

 ***Age 18 and under only. ADP covers 50% up to a maximum benefit
     of $1000.00/person. This is a lifetime benefit.