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Plan Details & Options:
:
| Plan Options | Rates |
|---|---|
| BasicOne | Rate Chart |
| ClassicOne | Rate Chart |
| PremierOne | Rate Chart |
Preventive Care
Routine oral exams—limited to 2 per calendar year
Prophylaxis (the cleaning and scaling of teeth) — limited to 2 per calendar year
Topical application of fluoride—for dependent children under age 19; limited to 1 per calendar year (not applicable in all states)
Diagnostic Care*
Intra-Oral Occlusal Film
Bitewing X-rays (up to a set of 4)—limited to 1 per calendar year
Full mouth X-rays (Panoramic film or Full series)— no less than 36 months apart
Basic Care*
Simple extraction
Pin retention—per tooth, in addition to restorations
Fillings (restorations)
Amalgam restorations
Composite restorations—limited to anterior teeth and bicuspids
Sedative fillings
Antibiotic injections administered by a Dentist
Maintenance Prosthodontics
Denture repairs/Adjustments
Denture Rebase—no less than 24 months apart
Denture Reline—no less than 24 months apart
Major Care*
Endodontic treatment
Periodontic services
Inlays, onlays and crowns
Prosthetic services—dentures or bridges
Oral surgery
*Applies only to ClassicOne and PremierOne options
Exclusive Features:
- Choice of $750 or $1,250 maximum per person
- No waiting period for Preventative Care
- Eligible for ages 18 years and older
- Benefits for preventive, diagnostic, basic, and major services
- Automatic Bank Draft, Visa, MasterCard, or Discover
Is there a free look period?
If you are not completely satisfied with this coverage, and you have not filed a claim, you may return the Certificate of Insurance within 10 days and receive a premium refund. Enrollment and Administrative fees are non-refundable.
What is the calendar year maximum?
The maximum amount payable for all Covered Dental Charges in any calendar year as shown in the Coverage Schedule. The Calendar Year Maximum will apply to each insured person.
What is the Maximum Allowable Charge (MAC)?
The BasicOne plan is a PPO plan using the Dentemax PPO network and fee schedule for in and out of network benefits. The MAC benefit is payable as a percentage of the network fee schedule regardless of whether the treatment is provided by a network provider. Out-of-network charges in excess of the net work fee schedule are the responsibility of the covered person.
