Oral Health Services
ACCESS
Presented by
Dental Plans, Inc.
1
(800) 578-2082
Visit
our web site
SUMMARY
OF BENEFITS AND COPAYMENTS
These procedures are
performed as needed and deemed necessary by your Provider Dentist subject to
the Limitation, Exclusions and Governing Administrative Policies of the
program.
Enrollee
Pays
DIAGNOSTIC
Oral examination..................................................
.No
Cost
Bitewing x-rays 4
films
.No Cost
Panoramic film.....................................................
.No
Cost
Pulp vitality tests................................................
.No
Cost
PREVENTIVE
Prophylaxis (adult/child) two per 12 month
period
..No Cost
Topical application of fluoride including, excluding
prophylaxis (to age 19)
..No Cost
RESTORATIVE
Amalgam - one surface,
primary.......................
....$
36.00
Amalgam - four surfaces, primary....................
$
66.00
Amalgam - one surface,
permanent..................
$
36.00
Amalgam
- four surfaces, permanent...............
$
66.00
Resin - one surface,
anterior.............................
$
58.00
Sedative filling
.............................................................................................$35.00
ORAL SURGERY
Simple extraction - single tooth........................
.$ 46.00
Surgical removal of erupted tooth....................
.$ 85.00
Removal of impacted tooth - soft tissue.........
.$ 99.00
Removal of impacted tooth - completely
bony
$155.00
Alveoloplasty in conjunction with extraction per
quadrant
$ 92.00
Alveoloplasty with no extraction per
quadrant
$412.00
PERIODONTICS
Gingivectomy / gingivoplasty, 4+ teeth
per quadrant
.$214.00
Gingival Flap procedure, incl. Root planning 4+
contiguous teeth, per quad
..
.$253.00
Osseous surgery, flap entry & closure, 1-3 teeth
per quadrant
.
$408.00
PROSTHETICS
Crown - porcelain/ceramic substrate...............
..$357.00
Crown - porcelain fused to metal......
..$380.00
Crown - full cast
metal
...............................................................................................$350.00
Denture - complete upper /lower......
...$472.00/$472.00
Denture - upper or lower partial w/resin
base
.$521.00/$521.00
Replace missing/ broken denture teeth - per
tooth
$ 47.00
Rebase upper/lower partial denture.................
..$181.00
Denture reline upper/lower, partial denture (chairside)
.$99.00
ENDODONTICS
Endodontics: Anterior, Bicuspid, Molar (excluding
final restoration
..
..$269.00; $328.00; $385.00
Root canal therapy, retreatment,
anterior, bicuspid, molar
..
.$314.00;
$371.00; $446.00
ADJUNCTIVE GENERAL SERVICES
Palliative (emergency) treatment of
............... Dental
pain minor................................
N/C
Sealant per tooth.............................................
.N/C
Limited Oral Exam-Problem focused
.N/C
·
HOW IT WORKS
When you enroll in
OHS, select a Participating Dentist from the list. Out of network reimbursements do apply. 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 an OHS
membership card. 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 may be performed by a panel network for co-payment prices. Out of
network providers will be given a maximum reimbursement for each covered
procedure.
·
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.
OHS
Access Plan
Bi-Weekly
Payroll Deduction
Individual $18.00
Individual & one dependent $26.00
Family $33.00
Monthly Bank Draft Rate
Individual $39.00
Individual & one dependent $56.33
Family $71.50
- 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 OHS program
there are no required deductibles to pay so your benefits begin immediately.
Φ NO PRE-EXISTING CONDITIONS RESTRICTED
These conditions are
not excluded in an OHS 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
The OHS program offers
services in dental specialty areas.
These include periodontics (treatment of diseased gums and bone),
endodontics (root canal therapy), oral surgery procedures, and
orthodontics.
- SUMMARY OF BENEFITS
The OHS 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 OHS panel dentist. (See Description of Benefits and Co-payments
on reverse side.)
Please
note: With OHS you receive the same
benefits at the specialist office that you would receive from a general
Dentist. With all other prepaid
dental plans you only receive a 25% discount of specialty care, which is much
higher. For more information on why OHS
should be your prepaid Dental Plan, please call:
1 (800) 578-2082
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.
8/2005