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Issue ages: 18 to Any Age Dependent children age: Last day of the year they turn 26 Plan includes $7,000 term life | |||||||||||||||||||||
Enrollment Deadline | 18th of the month prior to effective date | ||||||||||||||||||||
Provider Lookup (Solstice PPO) | http://www.solsticebenefits.com/provider-search.aspx (Solstice PPO) | ||||||||||||||||||||
Find a Dental Provider (How To) | |||||||||||||||||||||
Plan Summary & Limitations, Non-Covered Services, and Exclusions | |||||||||||||||||||||
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Annual deductible applies to preventive and diagnostic services | No (In Network) No (Out-of-Network) | ||||||||||||||||||||
Solstice BenefitsBooster Included (Increasing Calendar Year Maximum Benefit) | Yes | ||||||||||||||||||||
Preventive Waiver Saver Included (P&D Services Do Not Accumulate Towards Annual Maximum) | No | ||||||||||||||||||||
Orthodontic eligibility requirement | N/A |
COVERED SERVICES | NETWORK PLAN PAYS* | OUT-OF-NETWORK PLAN PAYS** | BENEFIT GUIDELINES |
PREVENTIVE & DIAGNOSTIC SERVICES | |||
Periodic Oral Evaluation | 100% | 100% | Limited to two (2) times per consecutive twelve (12) months. |
Routine Radiographs | 100% | 100% | Bitewings: Limited to one (1) series of films per consecutive twelve (12) months. |
Non-Routine - Complete Series Radiographs | 100% | 100% | Complete Series/Panorex: Limited to one (1) time per consecutive thirty-six (36) months. |
Prophylaxis (Cleanings) | 100% | 100% | Limited to (2) prophylaxis in any twelve (12) consecutive months, to a maximum of (2) total prophylaxis and periodontal maintenance procedures in any twelve (12) consecutive months. |
Fluoride Treatment | 100% | 100% | Limited to Covered Persons under the age of sixteen (16) years, and to one (1) time per consecutive twelve (12) months. |
Sealants | 100% | 100% | Limited to Covered Persons under the age of sixteen (16) years, and to one (1) time per first or second unrestored permanent molar every consecutive thirty-six (36) months. |
Space Maintainers | 100% | 100% | Limited to Covered Persons under the age of sixteen (16) years, one (1) time per consecutive sixty (60) months. Benefit includes all adjustments within six (6) months of installation. |
Palliative Treatment | 100% | 100% | Covered as a separate benefit only if no other service, other than exam and radiographs, were done during the visit |
BASIC SERVICES | |||
Restorations (Amalgam or Composite) | 80% | 80% | Multiple restorations on one (1) surface will be treated as a single filling. |
Simple Extractions | 80% | 80% | Limited to one (1) time per tooth per lifetime. |
Oral Surgery (includes surgical extractions) | 50% | 50% | Extractions: Limited to one (1) time per tooth per lifetime. |
Periodontics | 50% | 50% | Periodontal Surgery: Limited to one (1) quadrant or site per consecutive thirty-six (36) months per surgical area. Scaling and Root Planing: Limited to one (1) time per quadrant per consecutive twenty-four (24) months. Periodontal Maintenance: Limited to two (2) periodontal maintenance in any twelve (12) consecutive months, to a maximum of two (2) total prophylaxis and periodontal maintenance procedures in any twelve(12) consecutive months. |
Endodontics | 50% | 50% | |
Anesthetics | 80% | 80% | General Anesthesia: When clinically necessary. |
Adjunctive Services | 80% | 80% | |
MAJOR SERVICES (12 Month Waiting Period) | |||
Inlays/Onlays/Crowns | 50% | 50% | Limited to one (1) time per tooth per consecutive sixty (60) months. |
Dentures and other Removable Prosthetics | 50% | 50% | Full Denture/Partial Denture: Limited to one (1) per consecutive sixty (60) months. No additional allowances for precision or semi precision attachments. |
Fixed Partial Dentures (Bridges) | 50% | 50% | Bridges: Limited to one (1) time per tooth per consecutive sixty (60) months |
ORTHODONTIC SERVICES | |||
Diagnose or correct misalignment of the teeth or bite | Not Covered | Not Covered | Not Covered |