|Individual EPO Dental summary of benefits|
|Visit charge||$35 per visit|
|BENEFIT WAITING PERIODS|
|Diagnostic and preventive services||None|
|Major dental services||6 months|
|Orthodontic services||6 months|
|BRIEF SUMMARY OF COVERED SERVICES AND SERVICE COPAYS|
|DIAGNOSTIC AND PREVENTIVE SERVICES|
|Routine and emergency oral evaluations||Covered with the office visit copay|
|Teeth cleanings (adult and child)|
|Sealants (per tooth)|
|Head and neck cancer screening|
|Oral hygiene instruction|
|RESTORATIVE DENTISTRY (Member is also responsible for office visit copay)|
|Fillings, amalgam (per tooth)||$45 copay|
|MAJOR AND OTHER SERVICES (Member is also responsible for office visit copay)|
|Porcelain-metal crown||$500 copay|
|Out-of-area emergency care reimbursement (50 miles or more from a WDG office)||You pay charges in excess of $100|
|Complete upper or lower denture||$600 copay|
|Bridge (per tooth)||$500 copay|
|Routine extraction (single tooth)||$75 copay|
|Surgical extraction||$190 copay|
|ORTHODONTIA (Member is also responsible for office visit copay)|
|Pre-orthodontic service||$150 copay; applies toward comprehensive orthodontic copayment if patient accepts treatment plan|
|Comprehensive orthodontia||$3,000 copay per case|
|OPTIONAL VISION BENEFIT RIDER (Administered directly through LifeMap)|
|You may elect to add vision benefits to your dental coverage. The vision benefit reimburses up to $150 per member for vision exams and/or hardware, including LASIK, every 24 months.|
These services and supplies are not covered:
This is a brief summary of benefits. For full coverage provisions, including a description of limitations and exclusions, refer to your policy.
There is a six-month waiting period for all Orthodontic Services and some Major Services, including Permanent Crowns and some Prosthetic Services and Supplies. Please note: If you cancel Individual Managed Care Dental, there is a 12-month waiting period before you can re-enroll. The benefits of this plan are not subject to any coordination of benefits provision.
This is a web site from CDA Insurance LLC. CDA Insurance LLC is not an insurance carrier, we are an agency that represents many companies offering products to the general public and also to medicare recipients. We do our best to assure that all information presented on our web site is current and accurate.
If you have current coverage and are applying for new coverage from a different company, do not cancel the existing coverage until your new policy has been issued.