DentaQuest® Personal Dental Plan Plus

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 $100 per covered individual / $300 per family 50%
Complex dental services $100 per covered individual / $300 per family 30%
Orthodontics (under age 19) Not a covered service Not a covered benefit

Waiting Period: There are never waiting periods for Preventative or Diagnosis services.
Restorative and other Basic Services are subject to a six (6) month waiting period. Complex Dental Services are subject to an eighteen (18) 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 $1,250 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%

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%

Major Restorative
Crowns and Onlays Once per tooth every five years 30%
Replacement crowns Once every 60 months per tooth 30%
Implants Once per tooth per 60 months 30%

Endodontics
Root canal treatment Once per tooth 30%
Vital pulpotomy Limited to deciduous teeth 30%

Periodontics
Periodontal cleaning Must meet periodontal guidelines 30%
Scaling and root planing Once per quadrant per 24 months 30%
Periodontal surgery Must meet periodontal guidelines 30%

Dentures and Bridges
Complete or partial dentures Once every 60 months 30%
Fixed bridges Once every 60 months 30%
Replacement dentures or fixed bridges Once every 60 months 30%
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%
Surgical extractions Once per tooth 30%

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

Anesthesia
General anesthesia Allowed with covered surgical services only 50%