DentaQuest® Dental Plans Basic

PPO plans are available in the following states: AZ, GA, IL, MO, OH, & TX with out of network coverage
EPO Plans are sold in FL, IN, IL, PA, TN & VA with no out of network coverage

Coverage Summary

Coverage type Calendar year deductible DentaQuest will pay
 
Diagnostic and preventive services None 100%
Restorative and other basic services Not a covered service Not a covered benefit
Complex dental services Not a covered service Not a covered benefit
Orthodontics (under age 19) Not a covered service Not a covered benefit

What is the waiting period for services? There are never waiting periods for Preventative or Diagnosis services.
Restorative and other Basic Services are subject to a six (6) month waiting period.

 
Is there out of network coverage?
In AZ, GA, IL, MO, OH, & TX: YES, DentaQuest will pay the same percentage for covered services received in and out of network. But if the member chooses to see a non-contracting dentist (out of network), they will be responsible for the difference between the plan’s allowable charges (what contracting dentists receive for payment from DentaQuest®) and the dentist’s usual and customary fees (what the dentist charges cash-paying patients). This means the member saves more by receiving care from a contracting dentist.
 
In FL, IN, LA, TN and VA: NO, If a member visits a dentist who is not in our network, they will be responsible for the entire cost of the services you receive. Members may only receive covered benefits from a non-participating dentist in the event of an emergency dental condition
 
What are the annual limits and maximums?
The total benefits are limited to a maximum of $1,000 for each plan year.
 
Do Deductibles apply to diagnostic and preventive services?
No, the deductible only applies to Restorative, Basic and Complex dental services 
 
Are Dependents Covered? Yes, Dependent children are covered up to and including age 26.


 
Category / Procedure Benefit limits DentaQuest will pay
 
Diagnostic
Initial oral exam Once per dentist per 60 months 100%
Periodic oral exam Twice per plan year 100%
Full mouth X-rays Once every 60 months 100%
Bitewing X-rays Twice per plan year 100%
Single tooth X-rays As needed 100%

Preventive
Routine cleaning Twice per plan year 100%
Fluoride varnish application Children under 19 – Twice per plan year 100%
Topical fluoride treatment Children under 19 – Twice per plan year 100%
Space Maintainers Only for children under age 14 and not for the replacement of primary or permanent front teeth 100%
Sealants Sealants on unrestored permanent molars, once per tooth for children under 16. 100%
Repair crowns or onlays Once per tooth 50%
Recement Crowns Once per tooth every 12 months 50%

Restorative
Silver fillings Once every two years per surface per tooth 50%
White fillings (front teeth) Once every two years per surface per tooth 50%
Temporary fillings Once per tooth 50%
Stainless steel crowns Under age 15 – One per tooth in 60 months 50%

Dentures and Bridges
Rebase or reline dentures Once every 36 months 50%
Repair of dentures or fixed bridges Once every 12 months 50%
Adding teeth to existing dentures Once per tooth 50%
Recementing fixed bridges Once every 12 months 50%

Oral Surgery
Simple extractions Once per tooth 50%

Emergency dental care
Minor treatment – pain relief Three occurrences in six months 50%

Anesthesia
General anesthesia Allowed with covered surgical services only 50%