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BUYING POWER

Access to the insurance plans and large group pricing on this website is predicated upon joining Elevate Wellness, a national association with over 80,000 members. A $5 per month membership fee is all you pay, whether you buy a plan for one person, multiple people, or multiple plans. Learn more


Plan Description

Preventive oral care not only provides benefits for your overall health, it also helps avoid unexpected expenses like oral surgery. Our large network and flexible coverage options help keep your out-of-pocket costs down.

Network  
Enrollment Deadline 17th of month Prior to Effective date
Network PDP Plus
Provider Search Click here
States Not Available
AK, ID, LA, ME, MD, MT, NH, NM, OR, SD, WA
Coverage Type* In-Network Out-of-Network
Type A – Preventive 100% of Negotiated Fee* 100% of Negotiated Fee*
Type B – Basic 80% of Negotiated Fee* 80% of Negotiated Fee*
Type C – Major
50% of Negotiated Fee*

50% of Negotiated Fee*
Type D – Orthodontia
50% of Negotiated Fee*

50% of Negotiated Fee*
Deductible**  
Individual $25** $25**
Family $75** $75**
Annual Maximum Benefit
Per Person $3,000 (Annual Combined)
Orthodontia Lifetime Maximum
Per Person $2,000 (Annual Combined)
   
List of Primary Covered Services & Limitations How Many/How Often – All Plans
Type A - Preventive  
Oral Examinations One time in 6 months.
Prophylaxis (cleanings) One time in 6 months.
Sealants One application of sealant material every 3 years for each non-restored, non-decayed 1st and 2nd molar of a dependent child up to 19th birthday.
Space Maintainers One in 3 years for dependent children up to 14th birthday .
Topical Fluoride Applications Two times in 12 months for a dependent child under age 19.
X-rays Full mouth X-rays: one per 5 calendar years.

Bitewing X-rays: one set per calendar year for adults and one set per calendar year for dependent children under age 19.
Type B - Basic Restorative  
Amalgam Fillings One replacement per surface in 24 months
Resin Composite Fillings (excludes coverage for composite fillings on molars) Unlimited.
Examinations-Problem Focused Combined with Examinations Limit.
Periodontics Periodontal scaling and root planing once per quadrant, every 24 months.

Total number of periodontal maintenance treatments and prophylaxis cannot exceed four treatments in 12 months.

Non-Surgical procedures
Endodontics Pulpotomy, Pulp Capping, Pulp Therapy
Oral Surgery Simple and Surgical Extractions.
Prefabricated Crowns One per tooth in 10 calendar years.
Type C - Major Restorative  
Periodontics Periodontal Surgery: one per quadrant in any 36 month period.
Full Mouth Debridement One per lifetime
Endodontics Root Canal treatment limited to one per tooth per lifetime.
Crown Buildups/Post Core One per tooth in 10 calendar years.
Crowns/Inlays/Onlays Replacement: one every 10 calendar years per tooth.
Dentures Rebases/Relines: one in 36 months.

Adjustments: one in 12 months.

Repairs: one in 12 months.

Recementations: one in 12 months.
Bridges and Dentures Dentures and bridgework replacement: one every 10 calendar years.

Replacement of an existing temporary full denture if the temporary denture cannot be repaired and the permanent denture is installed within 12 months after the temporary denture was installed.
Tissue Conditioning One in 36 months.
Implants Replacement: one per tooth position every 10 calendar years.

Repairs: one per tooth in 12 months.

Supported Prosthetic: one per tooth every 10 calendar years.
Occlusal Adjustments One in 12 months.
Consultations Two in 12 months.
General Anesthesia When dentally necessary in connection with oral surgery, extractions or other covered dental services.
Type D - Orthodontia (Platinum Plan only) Your Children, up to age 19, are covered while Dental Insurance is in effect.

All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.

Payments are on a repetitive basis.

20% of the Orthodontia Lifetime Maximum will be considered at initial placement of the appliance and paid based on the plan benefit’s coinsurance level for Orthodontia as defined in the Plan Summary.

Orthodontic benefits end at cancellation of coverage.
*Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any co-payments,
deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

** Applies only to Type B & C Services.
 
 






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