Product_PlanPlus

Benefit Maximum

Individual: $1250

Deductible

Individual: $100

Family: $300

Waiting Periods

Restorative & Other Basic Services: 6 months
Complex Dental Services: 18 months

Benefits Summary

Network

TX DentaQuest Personal Dental Plan

Description

Our balanced plan between cost and coverage provides coverage for the important preventive and diagnostic dental services along with coverage for restorative services like:

Simple Extractions
Fillings
Repair of dentures or crowns
Deductibles do not apply to diagnostic and preventive services.
Waiting periods do not apply to diagnostic and preventive services.

Coverage (In Network & Out of Network)

This plan has out of network coverage. DentaQuest will pay the same percentage of the allowable charges for covered services received in and out of network. If you choose to see a non-contracting dentist (out of network), you will be responsible for the difference between the plan’s allowable charges (what contracting dentists receive for payment from DentaQuest) and the dentist’s usual and customary fees (what the dentist charges cash-paying patients).

Diagnostic/Preventive

Category/Procedure	Qualification	In Network (We Pay)	Out of Network (We Pay)
Bite-wing X-rays	Once per 6 months	100% under 19, 100% 19 and older	100% under 19, 100% 19 and older
Cleaning & Exams	Twice per calendar year	100% under 19, 100% 19 and older	100% under 19, 100% 19 and older
Topical fluoride treatment	Twice per calendar year (covered for age under 18)	100% under 19, 100% 19 and older	100% under 19, 100% 19 and older
Sealants	Once per 48 months (covered for age under 15)	100% under 19, 100% 19 and older	100% under 19, 100% 19 and older

Restorative & Other Basic Services

Category/Procedure	Qualification	In Network (We Pay)	Out of Network (We Pay)
Palliative (emergency) treatment of dental plan	Three times per twelve months	50% under 19, 100% 19 and older	50% under 19, 100% 19 and older
Silver fillings	Once per 24 months	50% under 19, 100% 19 and older	50% under 19, 100% 19 and older
White fillings (front teeth)	Once per 24 months	50% under 19, 100% 19 and older	50% under 19, 100% 19 and older
Simple tooth extraction	As needed	50% under 19, 100% 19 and older	50% under 19, 100% 19 and older

Complex Dental Services

Category/Procedure	Qualification	In Network (We Pay)	Out of Network (We Pay)
Crowns	Once per 24 months (covered for age over 12)	0% under 19, 30% 19 and older	0% under 19, 30% 19 and older
Root Canals	Once per tooth	30% under 19, 30% 19 and older	30% under 19, 30% 19 and older
Periodontics	As needed	0% under 19, 30% 19 and older	0% under 19, 30% 19 and older
Denture/Bridges	Once per 60 months (covered for age over 16)	0% under 19, 30% 19 and older	0% under 19, 30% 19 and older