|
| |||||||||||||||||||||
Automatic Monthly Bank Draft
Accounts are drafted on the 15th of each month prior to the month of benefits.
A monthly administration charge is included in the fees below.
Individual
$12.24
Individual & One Dependent
$19.84
Family
$30.57
$35.00 Enrollment Fee
Annual Prepayment Fees | |
Individual | $131.82 |
Individual & One Dependent | $223.08 |
Family | $351.86 |
The following is a sample of some frequently used dental procedures. When you enroll for the plan, you will pay reduced fees called co-payments. These reduced fees are only available from providers who participate in our network. After you enroll, a complete list of co-payments will be mailed to your home along with your Individual Dental Service Agreement. The sample below demonstrates potential savings with the Secure Choice plan and may not reflect your actual results.
Dental Treatment | With Secure Choice | Average Retail Charges† | ||
Appointments |
|
| ||
| Periodic Oral Evaluation | No Charge | $31 | |
| Limited Oral Exam | $25 | $46 | |
| Comprehensive Oral Evaluation | No Charge | $49 | |
Diagnostic Dentistry |
|
| ||
| Complete X-Ray Series, Including Bitewings | $10 | $89 | |
Preventive Dentistry |
|
| ||
| Routine Cleaning - Adult (once every 6 mos.) | $10 | $60 | |
| Routine Cleaning - Child (once every 6 mos.) | $10 | $42 | |
| Application Of Fluoride (up to 18 years of age) | No Charge | $24 | |
| Oral Hygiene Instruction | No Charge | $29 | |
| Application Of Sealant, Per Tooth | $20 | $34 | |
| Fixed Space Maintainer | $85* | $217 | |
Fillings/Crowns |
|
| ||
| Silver Fillings |
|
| |
|
| One Surface | $25 | $77 |
|
| Two Surfaces | $30 | $95 |
|
| Three Surfaces | $45 | $114 |
| White Fillings |
|
| |
|
| One Surface, Anterior | $50 | $95 |
|
| Two Surfaces, Anterior | $65 | $118 |
|
| Three Surfaces, Anterior | $80 | $143 |
|
| One Surface, Posterior | $85 | $107 |
|
| Two Surfaces, Posterior | $100 | $140 |
|
| Three Surfaces, Posterior | $105 | $171 |
|
| Crowns - Porcelain To High Noble Metal (cost of precious & semi-precious metal is additional) | $295* | $753 |
|
| Core Buildup | $55 | $168 |
Root Canals |
|
| ||
|
| Anterior | $145 | $484 |
|
| Bicuspid | $225 | $574 |
|
| Molar | $295 | $724 |
Periodontics |
|
| ||
| Periodontal Scaling And Root Planing, Per Quadrant | $90 | $166 | |
| Full Mouth Debridement (complicated cleaning) | $90 | $106 | |
Dentures |
|
| ||
| Complete Denture - Upper | $385* | $864 | |
| Complete Denture - Lower | $385* | $851 | |
| Partial Denture - Upper | $410* | $580 | |
| Partial Denture - Lower | $410* | $768 | |
Oral Surgery |
|
| ||
| Single Tooth Extraction | $25 | $77 | |
| Removal Of Impacted Tooth |
|
| |
|
| Soft Tissue | $105 | $206 |
|
| Partial Bony | $140 | $268 |
|
| Complete Bony | $165 | $311 |
|
| Complete Bony with complications | $205 | $361 |
Orthodontics |
|
| ||
| Orthodontic treatment for children and adults is provided at a 25% reduction from Plan Specialist's normal retail charges. | |||
* The Plan Dentist you select may not perform all procedures listed. The co-payments shown apply to those Plan Dentists who perform those services. Therefore, you are encouraged to discuss availability of the scheduled services with your Plan Dentist. Charges for procedures not listed on the Co-payment Schedule that are performed by your Plan Dentist are not covered under the Secure Choice Plan.
Should you require dental services that your selected Plan Dentist is unable to provide, you may obtain those services from a Plan Specialist at a reduced rate. No referral is needed from your Plan Dentist in order for you to obtain services from a Plan Specialist. There is no applicable co-payment schedule for Plan Specialist services. Instead, the following reductions off the Plan Specialist's normal retail charges apply to all services received from a Plan Specialist. A 15% reduction applies if the Plan Specialist is an endodontist. A 25% reduction applies if the Plan Specialist is any other type of specialist, including but not limited to an orthodontist. You are responsible for paying the entire reduced charge at the time the service is received, or in accordance with the Plan Specialist's billing procedures.
Payment for each service of a Non-Plan Dentist or Non-Plan Specialist (at the provider's normal retail charge) is your responsibility, except for limited Plan Benefits for covered dental Emergency Services for temporary pain relief.
* Members are responsible for additional lab fees for these services.
· The Average Retail Charges were determined by Assurant Employee Benefits claims analysis for the year 2003 and are adjusted annually as the market changes. The Retail Charges represent a mean average rounded to the nearest dollar representing what you may pay without the plan services and are given as a sample only. After you have enrolled, a complete list of your specific dental co-payments will be sent to your home with your Dental Service Agreement.
· Please refer to your specific Dental Service Agreement for a complete explanation of your benefits and limitations. The above information is given to assist persons with a general understanding of this program and is not designed to be complete in its coverage of benefits and limitations.