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

• Outpatient mental illness is limited to 12 visits per calendar year.
• Inpatient mental illness is limited to 8 days per calendar year.
• 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 12 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.
• Emergency care covered services include the medical examination and ancillary tests required in determining the extent of an emergency medical condition. Examples include but are not limited to: Suspected heart attach, serious burn, loss of consciousness, poisoning, bleeding that does not stop and severe pain.
• Acupuncture is limited to 12 treatments per calendar year.
• Spinal manipulation is limited to 10 treatments per calendar year.
• Inpatient rehabilitation care is limited to $15,000 per calendar year.
• Outpatient rehabilitation care including massage therapy is limited to $1,500 per calendar year.
• Neurodevelopmental therapy is limited to $1,500 per calendar year for children age 6 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.
• Ground and air ambulance combined is limited to $5,000 per calendar year (does not apply to emergent use).
• 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.
• The following will be covered only after nine months of enrollment: preexisting conditions, allergies, otitis media (ear infections), removal of tonsils and adenoids and sterilization procedures. 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.
• Services or supplies that are not medically necessary.
• Chemical dependency.
• Services related to or supporting infertility and reversal of sterilization procedures.
• Orthognathic surgery.
• Temporomandibular joint disorder.
• 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.
• 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 where specifically listed).
• 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 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.