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HealthState PPO HMO
Life InsuranceDentalVisionSupplemental |
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Dental PPO
With the PPO Dental plan, you may choose to receive care from any dentist; your cost is lower when you use network dentists. You generally have an annual deductible to meet before the plan starts paying benefits, and then you pay a percentage of the cost for the care you receive. The PPO covers adult and child orthodontia. Premiums shown do not include the 2% administrative fee.
| PPO | Indemnity with PPO | |||
|
|
CompBenefits Preferred Plus |
Ameritas Dental |
Assurant Freedom Advance |
|
|
Monthly Premiums |
$26.82
|
$8.84
|
$38.35
|
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In-Network |
Out-of-Network |
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Calendar Year Deductible |
Employee: $25 |
Employee: $50 |
$50 |
$50/person; |
|
Calendar Year Maximum |
$1,200 per person |
$1,200 per person |
$1,000 per person |
$1,250/person in network; |
|
***Preventive Care (no deductible) |
You pay |
You pay |
You pay |
|
|
Periodic oral exam (ADA 120) |
$0 |
20% |
Cost above $14 |
$0 |
|
Bite-wing X-rays four films (ADA 274) |
$0 |
20% |
Cost above $20 |
$0 |
|
Cleanings - Dental Prophylaxis Adult (ADA 1110) |
$0 |
20% |
Cost above $30 |
$0 |
|
Fluoride treatment, child (ADA 1203) |
$0 |
20% |
Cost above $11 |
$0 |
|
Sealant, per tooth (ADA 1351) |
$0** |
20% |
Cost above $17 |
$0 |
|
Space maintainers - fixed bilateral (ADA 1515) |
$0** |
20% |
Cost above $174 |
$0 |
|
***Basic and Major Care (for PPO and Indemnity plans, deductible applies) |
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X-rays - intraoral - complete series including bitewings (ADA 210) |
$0 |
20% |
Cost above $45 |
20% |
|
Amalgam fillings - 2 surfaces, primary or permanent (ADA 2150) |
20% |
50% |
Cost above $32 |
20% |
|
Resin-based composite - 2 surfaces, anterior (ADA 2331) |
20% |
50% |
Cost above $38 |
20% |
|
Root canal - endodontic therapy - molar, excluding final restoration (ADA 3330) |
20% |
50% |
Cost above $238 |
75%* |
|
Periodontal surgery – gingivecotomy/gingivoplasty - 4 or more contiguous teeth per quadrant (ADA 4210) |
20% |
50% |
Cost above $100 |
75%* |
|
Periodontal scaling and root planing, 4 or more contiguous teeth per quadrant (ADA 4341) |
20% |
50% |
Cost above $52 |
75%* |
|
Surgical extraction of tooth, including wisdom teeth (ADA 7240) |
20% |
50% |
Cost above $104 |
20% |
|
General anesthesia, first 30 minutes (ADA 9220) |
20% |
50% |
Cost above $80 |
20% |
|
Porcelain Crowns fused to high noble metal (ADA 2750)++ |
50% |
70% |
Cost above $156 |
75%* |
|
Fixed bridges - pontic, pocelain fused to high noble metal (ADA 6240)++ |
50% |
70% |
Cost above $151 |
75%* |
|
Full lower denture (ADA 5120)++ |
50% |
70% |
Cost above $161 |
75%* |
|
Metalic inlay - 2 surfaces (ADA 2520)++ |
50% |
70% |
Not Covered |
75%* |
|
Lower partial dentures, cast metal - acrylic (ADA 5214)++ |
50% |
70% |
Cost above $193 |
75%* |
|
Re-cement crowns (ADA 2920) |
50% |
70% |
Cost above $20 |
75%* |
|
Relining complete upper denture - chairside (ADA 5730) |
50% |
70% |
Cost above $58 |
75%* |
|
Repairs to broken denture base (ADA 5510)++ |
50% |
70% |
Cost above $32 |
75%* |
|
***Orthodontia Care |
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Comprehensive orthodontic treatment of the adolescent dentition (full treatment case up to 24 months – including fixed/removable appliances) (ADA 8080) |
50%; $1,500 lifetime max benefit |
100% |
Not Covered |
50% (lifetime max reimbursement $1,000 per child) |
|
Comprehensive orthodontic treatment of the adult dentition (full treatment case up to 24 months – including fixed/removable appliances) (ADA 8090) |
50%; $1,500 lifetime max benefit |
100% |
Not Covered |
Not Covered |
*75% for first year; 50% for subsequent years of consecutive coverage
**limited to children under age 16
***A sample of American Dental Association (ADA) codes are shown to help
you more easily compare costs across plans.
++With some plans, these services may also require a separate payment
for metal and/or laboratory charges
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