Solstice PPO Dental 1500
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Plan Description
Bigger Value For A Brighter Smile.
Quality, affordable dental care... It's that simple. Solstice dental plans offer rich plans and unbeatable savings with the security of knowing that you will be protected from hidden fees and surprises. Plus, our large open-access provider network means that you'll never have to deal with frustrating roster restrictions again. Now that's something to smile about.
- 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 |
NON-ORTHODONTICS
Individual Annual Calendar Year Deductible
- $50
- $50
Family Annual Calendar Year Deductible
- $150
- $150
Maximum (the sum of all Network and Out-of-Network benefits will not exceed Maximum Benefits)
- $1500 per person per Calendar Year
- $1500 per person per Calendar Year
ORTHODONTICS
Individual Annual Calendar Year Deductible
NOT COVERED| 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
PREVENTIVE & DIAGNOSTIC SERVICES
NETWORK PLAN PAYS*
| Periodic Oral Evaluation | 100% |
| Routine Radiographsn | 100% |
| Non-Routine - Complete Series Radiographs | 100% |
| Prophylaxis (Cleanings) | 100% |
| Fluoride Treatment | 100% |
| Sealants | 100% |
| Space Maintainers | 100% |
| Palliative Treatment | 100% |
OUT-OF-NETWORK PLAN PAYS**
| Periodic Oral Evaluation | 100% |
| Routine Radiographsn | 100% |
| Non-Routine - Complete Series Radiographs | 100% |
| Prophylaxis (Cleanings) | 100% |
| Fluoride Treatment | 100% |
| Sealants | 100% |
| Space Maintainers | 100% |
| Palliative Treatment | 100% |
BENEFIT GUIDELINES
Limited to two (2) times per consecutive twelve (12) months.
Routine Radiographs: Bitewings:Bitewings: Limited to one (1) series of films per consecutive twelve (12) months.
Non-Routine - Complete Series Radiographs:Complete Series/Panorex: Limited to one (1) time per consecutive thirty-six (36) months.
Prophylaxis (Cleanings):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:Limited to Covered Persons under the age of sixteen (16) years, and to one (1) time per consecutive twelve (12) months.
Sealants: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: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:Covered as a separate benefit only if no other service, other than exam and radiographs, were done during the visit
BASIC SERVICES
NETWORK PLAN PAYS*
| Restorations (Amalgam or Composite) | 80% |
| Simple Extractions | 80% |
| Oral Surgery (includes surgical extractions) | 50% |
| Periodontics | 50% |
| Endodontics | 50% |
| Anesthetics | 80% |
| Adjunctive Services | 80% |
OUT-OF-NETWORK PLAN PAYS**
| Restorations (Amalgam or Composite) | 80% |
| Simple Extractions | 80% |
| Oral Surgery (includes surgical extractions) | 50% |
| Periodontics | 50% |
| Endodontics | 50% |
| Anesthetics | 80% |
| Adjunctive Services | 80% |
BENEFIT GUIDELINES
Multiple restorations on one (1) surface will be treated as a single filling.
Simple Extractions:Limited to one (1) time per tooth per lifetime.
Oral Surgery (includes surgical extractions):Extractions: Limited to one (1) time per tooth per lifetime.
Periodontics: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.
Anesthetics:General Anesthesia: When clinically necessary.
MAJOR SERVICES (12 Month Waiting Period)
NETWORK PLAN PAYS*
| Inlays/Onlays/Crowns | 50% |
| Dentures and other Removable Prosthetics | 50% |
| Fixed Partial Dentures (Bridges) | 50% |
OUT-OF-NETWORK PLAN PAYS**
| Inlays/Onlays/Crowns | 50% |
| Dentures and other Removable Prosthetics | 50% |
| Fixed Partial Dentures (Bridges) | 50% |
BENEFIT GUIDELINES
Limited to one (1) time per tooth per consecutive sixty (60) months.
Dentures and other Removable Prosthetics: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):Bridges: Limited to one (1) time per tooth per consecutive sixty (60) months
ORTHODONTIC SERVICES
NETWORK PLAN PAYS*
| Diagnose or correct misalignment of the teeth or bite | Not Covered |
OUT-OF-NETWORK PLAN PAYS**
Diagnose or correct misalignment of the teeth or bite Not CoveredBENEFIT GUIDELINES
Not Covered
