Dominion
Dental Services
Plan 603X
Presented by
Dental Plans, Inc.
1
(800) 578-2082
SUMMARY OF BENEFITS AND
COPAYMENTS
Enrollee pays
DIAGNOSTIC
Office Visit/Infectious Disease Control...........
..$ 10.00
Oral examination..................................................
.
...No
Cost
Bitewing radiograph(s)
..........................
.
.
..No Cost
Panoramic film.....................................................
.
.
.. $30.00
Pulp vitality tests................................................ .. ..No Cost
PREVENTIVE
Prophylaxis (adult/child) one per six month period ..Adult- 13.00; Child - $10.00
Topical application of fluoride including, excluding prophylaxis (to age 19) No Cost
RESTORATIVE
Amalgam - one surface...................................... $ 37.00
Amalgam - four+ surfaces................................. $ 70.00
Resin - one surface.............................................
$ 66.00
Resin - four+ surfaces........................................
$ 114.00
Sedative filling.....................................................
$ 37.00
Pin retention, per tooth, add restorative.........
$ 20.00
ORAL
SURGERY
Routine extraction - single tooth, without
complication
... $ 50.00
Surgical removal of erupted tooth....................
$120.00
Removal of impacted tooth - soft tissue.........
$137.00
Removal of impacted tooth - completely
bony
$219.00
Alveoplasty per quadrant.................................
$128.00
PERIODONTICS
Gingivectomy per quadrant...............................
$255.00
Gingival flap procedure, per quadrant.............
$316.00
Root planing & periodontal
scaling, per quadrant
$
99.00
Osseous (bone) surgery, per quadrant...........
$359.00
Occlusal guards, by report................................
$258.00
PROSTHETICS
Crown - porcelain/ceramic.................................
$535.00
Crown - porcelain fused to metal......................
$497.00
Crown - full cast metal........................................
$470.00
Crown - resin with metal....................................
$495.00
Cast post & core in addition to crown............
$176.00
Denture - complete upper or lower...................
$606.00
Removable unilateral partial - 1 piece cast metal,
incl. clasps & teeth
.. $364.00
Rebase complete/partial upper & lower..........
$226.00
Reline complete/partial upper & lower............
$134.00
Reline upper/lower partial, lab..........................
$194.00
Bridge pontic metal.........................................
$470.00
ENDODONTICS
Root canal - anterior, excl. final restoration....
$296.00
Root canal - bicuspid, excl. final restoration...
$363.00
Root canal - molar, excl. final restoration........
$444.00
ADJUNCTIVE
GENERAL SERVICES
Palliative (emergency) treatment of .................
$ 40.00
Local anesthesia.................................................
No Cost
Consultation/second opinion, per session, by another
plan dentist
$
40.00
Broken appointment, w/o 24 hr notice - per 1/2
hr
$
23.00
ORTHODONTICS
Records & study models...................................
$413.00
Two year case, adolescent..............................
.. $3,422.00
Please note: This is only a summary of the co-payments and benefits. For more information on Dental Plans, please call:
1 (800) 578-2082
An
Evidence of Coverage will be sent to you upon enrollment.
·
HOW IT WORKS
When you enroll in
Dominion Dental Services, select a Participating Dentist from the list. This location is now the center for all of
your dental needs.
After you have
enrolled, you will receive a Combined Evidence of Coverage and Disclosure Form
that fully describes the benefits of your dental plan as well as a Dominion
Dental membership card. This card will
have the address and telephone number of your participating panel dentist. To receive all necessary dental care covered
by the plan, simply call your selected provider to make an appointment.
Remember to always
contact your selected panel dentist. Dental
services which are not performed by your panel provider nor prior authorized by
Dominion will not be covered by the Dominion Dental program.
·
WHO CAN JOIN
You can also enroll
your eligible dependents, which include your lawful spouse and unmarried
children; including step-children, legally adopted and foster children to the
limiting age as specified by state law.
Dominion
Dental Services - Plan 405X
Bi-Weekly Payroll Deduction
Individual $13.00
Employee + 1 $18.00
Family $23.00
Monthly Bankdraft Rates
Individual $28.17
Employee + 1 $39.00
Family $49.83
·
ADVANTAGES
Φ NO CLAIM FORMS
The dental location
you choose provides all primary dental services. There are no claim forms to complete or
percentage of usual charges for you to pay.
Φ NO DEDUCTIBLES
In the Dominion Dental
program there are no required deductibles to pay so your benefits begin
immediately.
Φ NO DOLLAR LIMIT OF DENTAL BENEFITS
No annual limit.
Φ NO PRE-EXISTING CONDITONS RESTRICTED
These conditions are
not excluded in a Dominion Dental program.
Exception: Work in progress.
Φ PREPAID PLAN SAVES ON DENTAL COST
Your out-of-pocket
savings could be substantial. You know
the exact cost prior to treatment and this aids in better fiscal planning for
you and your family.
Φ QUALITY REVIEW OF DENTAL PROVIDERS
On site audit of
participating dental locations to insure that established standards of quality
are maintained.
Φ SPECIALTY SERVICES
Should the services of
a specialist be necessary, you may be referred by your participating general
dentist to any participating specialist listed in our directory. If you are treated by a participating
specialist, you will receive a 25% reduction off that specialists normal
fees. Payment for services performed by
a non-participating specialist is the
responsibility of the member.
·
SUMMARY OF
BENEFITS
The Dominion Dental
program provides all reasonable and customary dental care (subject to the
provisions, limitations and exclusions as shown in the Combined Evidence of Coverage
and Disclosure Form) if care is rendered by your assigned Dominion Dental panel
dentist. There is no cost for covered
services to the primary enrollee or eligible dependent enrollee except for co-payments
on certain procedures. (See
Description of Benefits and Co-payments on reverse side.)
·
EMERGENCY
SERVICES
You are also covered
for out-of-area dental emergencies. This
program will pay dental expenses incurred up to a maximum of $50.00 during each
12 calendar months. Out-Of-Area means
35 miles or more from your selected Dominion Dental participating dentists
office.
Please
note: With Dominion Dental you receive a
25% discount on specialty care.
For
more information on why Dominion Dental should be your prepaid Dental Plan,
please call:
1
(800) 578-2082