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INDIVIDUAL - FAMILY
DENTAL PLANS
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InsuranceCompany.com is a specialist in dental care,
dental insurance plans, vision and prescription coverage programs. We
have
been in business since 1983 and
offer several national dental, vision and
prescription
programs depending upon the
state you live in...
You have selected the
PacifiCare
Dental Plan 511. Monthly premiums are
$15.00 for an
individual, $24.53 for a couple, and $34.61 for a family plan.
This is a dental insurance only plan.
Here's your chance to take the hassle out of maintaining a healthy and attractive smile. You just show up for your dental appointment and make your
co-payment, no claim forms, no deductibles - what could be easier?
We know cost is important, that's why the dental preventive care is so easy to get...and with low monthly rates and
co-payments. Check the rates below and see how easy it is for you and/or your family to enjoy quality dental coverage while maintaining your budget.
NO DEDUCTIBLES - NO CLAIM FORMS
Your full benefits begin promptly. There are no deductibles and no yearly limits on benefits, and there are no claim forms to fill out. Your savings are in place when you visit your dentist.
PREVENTIVE SERVICES AT NO CHARGE
Many services such as x-rays, cleaning and fluoride treatments are provided at no charge! So maintaining good oral health has never been easier - or more economical. Additional preventive services at no charge include: office visits; x-rays (full mouth) once every 6 months; teeth cleaning - prophylaxis once every six months; topical fluoride (under age 18).
| Your online request must be
processed on or before the 20th of the month prior to the coverage effective
date. This dental plan starts on the 1st of next month if you have enrolled by
the 20th... If you have any questions regarding the enrollment period please contact
our office for assistance. |
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| Office visit |
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No Charge |
| X-rays, full mouth |
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No Charge |
| Single film |
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No Charge |
| Each additional film |
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No Charge |
| Teeth cleaning |
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No Charge |
| Topical Fluoride (under age 18) |
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No Charge |
| Sealants (per tooth; under age 18) |
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Not Covered |
| Diagnostic casts (non-orthodontic) |
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$10.00 |
| Initial charting with pocket depth
summary |
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$5.00 |
| Emergency treatment (palliative) |
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$10.00 |
| Office visit (after hours) |
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$20.00 |
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Restorative Dentistry |
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| Amalgam restorations (cavities
involving permanent teeth) |
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| One tooth surface |
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$15.00 |
| Two tooth surfaces |
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$20.00 |
| Three tooth surfaces |
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$26.00 |
| Resin restorations, per tooth |
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$25.00 |
| As above, involving incisal edge |
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$28.00 |
| Pin retention in addition to final
restoration, per tooth |
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$5.00 |
| Sedative base |
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$7.00 |
| Oral Surgery |
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| Extraction (uncomplicated) |
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$16.00 |
| Each additional tooth (same visit) |
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$10.00 |
| Soft tissue impaction |
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$50.00 |
| Partially bony impaction |
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Not Covered |
| Completely bony impaction |
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Not Covered |
| Biopsy of oral tissue (soft) |
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$10.00 |
| Biopsy of oral tissue (hard) |
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$16.00 |
| Surgical removal of an erupted tooth |
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$40.00 |
| Alveoloplasty (not in conjuction with
extractions) |
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$90.00 |
| Alveoloplasty in addition to tooth extraction, per
quad |
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$80.00 |
| Drain
abscess/intraoral |
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$30.00 |
| Drain
abscess/extraoral |
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$30.00 |
| Frenectomy |
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$50.00 |
| Endodontics |
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| Pulp capping (direct) |
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$10.00 |
| Pulp capping (indirect) |
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$24.00 |
| Therapeutic pulpotomy |
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$22.00 |
| Root canals |
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| Anterior |
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$100.00 |
| Bicuspid |
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$130.00 |
| Molar |
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$175.00 |
| Prefabricated post |
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$50.00 |
| Cast post and core |
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$65.00 |
| Periodontics |
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| Gingival curettage, per quadrant |
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$40.00 |
| Gingivectomy, per quadrant |
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$115.00 |
| Muco-gingival surgery, per quadrant |
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Not Covered |
| Gingivectomy, per tooth |
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$20.00 |
| Periodontal maintenance (once overy 6
months) |
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$20.00 |
| Occlusion adjustment |
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Not Covered |
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Crowns and pontics |
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| Stainless steel, primary tooth |
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$30.00 |
| Resin crown ^ |
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$85.00 |
| Full metal crown** |
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$145.00 |
| 3/4 metal crown** |
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$140.00 |
| Porcelain crown^ |
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$130.00 |
Porcelain with metal crown** ^
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$165.00 |
| Pontic, cast metal (base) |
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$65.00 |
| Cast post & core, in addition to
crown |
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$145.00 |
| Pontic, porcelain with metal** |
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$165.00 |
| Inlay recementation |
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$12.00 |
| Crown recementation |
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$12.00 |
| Bridge recementation |
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$18.00 |
** plus actual lab cost of gold. ^ not
for molars. |
| Prosthetics |
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| Denture adjustment |
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$12.00 |
| Replace tooth, per tooth |
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$22.50 |
| Denture repair |
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$28.00 |
| Denture reline (office) |
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$35.00 |
| Denture reline, lab processed |
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$65.00 |
| Stayplate |
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$60.00 |
| Partial denture, upper or lower
(including any conventional clasps, rests, and teeth) |
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$225.00 |
| Complete upper or lower denture |
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$250.00 |
| Teeth and/or clasps, extra, per unit
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$31.00 |
| Fixed space maintainer |
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$55.00 |
| Removable acrylic space maintainer |
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$55.00 |
| Clasps each, additional, for space maintainer |
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No Charge |
Dentist may charge $20.00 for
broken appointments if not notified at least 24 hours in
advance. *Most Pre-Existing Conditions Covered |
| Orthodontics |
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| Class I (teeth straightening) |
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$1895.00 |
| Class II (correction of overbite) |
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$1895.00 |
| Class III (correction of
underbite)
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$1895.00 |
The orthodontic benefit covers:
consultation, all necessary appliances, banding, and monthly office
visits for 24 months. Specific copayment levels have also been set
for start-up and retention services.
Orthodontic treatment
must be provided by a Panel Orthodontist. A
referral must be submitted by the assigned general dentist and
approved by the Plan. |
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LIMITATIONS AND EXCLUSION: CLICK
HERE
ARBITRATION: The Plan uses binding arbitration to resolve any and all disputes between the Plan and group or member, including, but not limited to, allegations against Plan of medical malpractice (that is an to whether any dental services rendered under the Plan were unnecessary or unauthorized or were improperly, negligently or incompetently rendered) and other disputes relating to the delivery of services under the Plan.
Plan, group and member each understand and expressly agree that by entering into the Plan services group subscriber agreement or enrolling in Plan and agreeing to be bound by the Plan subscriber agreement. Plan, group and member are each voluntarily giving up their constitutional right to have all such disputes decided in a court of law before a jury and instead are accepting the is of binding arbitration. Group and member further contracting provider including but not limited to claims against a Plan contracting provider for medical malpractice are not governed by the Plan subscriber agreement.
However Plan, group and member each expressly agree that the existence of any disputes between group or member and a Plan contracting provider, including but not limited to claims by groups or member against a Plan contracting provider for medical malpractice shall in no way affect the obligation to submit to binding arbitration all disputes between group or member and Plan.
LIMITATIONS: Dentures or partials once every five years and then only when dentures cannot be made serviceable; cleanings once every six months; redlines not more than twice per year; full mouth x-rays once every two years; all family members must be assigned to the same dental office; orthodontic treatment must be provided by a member of the Plan Orthodontic Panel.
EXCLUSIONS: Oral surgery requiring the setting of fractures or dislocations; treatment of malignancies, cysts or
neoplasms; dispensing of drugs; teeth extracted for orthodontic purposes; cosmetic dentistry; treatment of temporomandibular joint syndrome
(tmj); treatment by a specialist.
DISCLOSURE: An application is a request for coverage which if approved by the Plan would then become the enrollment form and would be used to issue an identification card and a Disclosure Form. Upon acceptance of the application by the Plan, your benefits will become effective on the first of the next month. Detailed limitations and exclusions, coverage benefits, co-payments, as well as other services offered, are given in full in the Disclosure Form provided when coverage becomes effective. The Insurance Company always reserves the right to make the final determination with respect to all aspects of this Dental Program.
This is not an attempt to describe coverages you may have or purchase but rather a brief description for sales purposes. Your coverage may vary and additional coverages are available that were not described here.
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