Dental Plan

Add our Individual Dentacare dental plan to round out your client's coverage. It offers:

• no deductible
• $15 copay for each visit
• no annual maximum for coverage

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These Benefits Are Limited

• We provide transplant coverage only to those who have been covered by us, or another insurer with similar transplant coverage, for a total of at least 24 months (or since birth), providing there is no lapse between the two coverages. Benefits are based on the recipient’s eligibility, not the donor’s. Our payment for certain covered transplant services and supplies is limited to a lifetime maximum of $250,000 per enrollee.
• Inpatient rehabilitation care is limited to $15,000 per calendar year. Neurodevelopmental therapy is limited to children age 17 and under.
• Outpatient rehabilitation care is limited to $1,500 per calendar year. Neurodevelopmental therapy is limited to children age 17 and under.
• Home health care is limited to 130 visits per calendar year.
• Skilled nursing facility care is limited to 100 days per stay.
• Durable medical equipment is limited to $2,500 per calendar year. This limit does not apply for medically necessary prosthetic or orthotic devices.
• Ground and air ambulance combined is limited to $5,000 per calendar year.
• Temporomandibular joint disorder benefit is limited to $1,000 per calendar year.
• Dental care is limited to the treatment of an accidental injury to natural teeth or fractured jaw and limited to $1,000 per calendar year. Diagnosis must be made within 6 months and treatment within 12 months of injury.
• Hospitalization for medically necessary dental care is limited to $1,000 per calendar year.
• Growth hormone benefit, when eligible according to the contract, is limited to $20,000 per calendar year.
• Alcoholism treatment is limited to $4,500 every 24 consecutive months.
• The following will be covered only after twelve months of enrollment: elective procedures, allergies, and sterilization procedures. Additionally, pre-existing conditions will be covered only after six months of enrollment. You may receive credit from prior creditable medical coverage, providing there is a less than 63-day lapse between the two coverages.

Services And Supplies Not Covered

• Immunizations for the sole purpose of travel or passport purposes.
• Services provided by a member of your immediate family.
• Charges in excess of the amount allowed according to the terms of the contract.
• Services or supplies that are not medically necessary.
• Mental health/chemical dependency.
• Acupuncture, naturopathy, faith healing services, and homeopathy, even when provided by plan participants.
• Services related to or supporting infertility and reversal of sterilization procedures.
• Orthognathic surgery.
• Custodial care, personal hygiene, and other forms of supervised self-care.
• Services and supplies provided for obesity or weight reduction, including complications arising from such treatment.
• Developmental and learning disabilities for age 18 and older.
• Chronic or long-term psychotherapy (services provided in excess of crisis intervention or short-term therapy).
• Services or supplies for the treatment of personality and gender identity
  disorders.
• Cosmetic/reconstructive services and supplies, including complications arising from such services.
• Experimental and investigational treatment, procedures, equipment, devices, and supplies.
• Treatment for addiction to tobacco, tobacco products, nicotine substitutes, or foods.
• Appliances or equipment primarily for personal comfort or convenience, and therapeutic devices including eyeglasses and hearing aids.
• Routine physical, mental, eye, hearing examinations, or eye exercises (except as specified in the contract).
• Surgery to alter the refractive character of the eye.
• Self-help training, instructional programs, and physical exercise programs (except where specifically listed).

These Pharmacy Benefits Are Limited

• The maximum quantity for pharmacy purchased prescription medications is a 30-day supply.
• Compound medications are only covered when one ingredient is a federal legend or state restricted medication.

These Pharmacy Benefits Are Not Covered

• Impotence and infertility medications.
• Experimental/investigational medications.
• Medications prescribed for cosmetic purposes.
• Smoking cessation products.