Download pediatric dental - Western Health Advantage

PEDIATRIC DENTAL
SMILE FOR KIDS DHMO HIGH (EHB)
EHB High Plan
Deductible
$0
Out of Pocket Maximum (OOP)/per person
$1,000
Out of Pocket Maximum (OOP) (2+ children)
$2,000
Annual Maximum
This information is a summary of benefits of the HIGH Essential Health
Benefit for Children. It lists the services available to you under this dental
plan as well as the Copayments associated with each procedure. This
summary provides a very brief description of some of the procedures
covered. For complete benefit information, members can refer to the
Combined Evidence of Coverage and Disclosure Form and Schedule of
Benefits on the WHA website at mywha.org; also available upon request.
In-Network
N/A
This plan is available for individuals up to age 19.
The following Copayments apply when services are performed by your
assigned Primary Care Dentist or a Contracted Specialist (with prior
approval from Access Dental). If Specialist Services are recommended
by your Primary Care Dentist, the treatment plan must be preauthorized in
writing by Access Dental prior to treatment in order for the services to be
eligible for coverage. All services are subject to Exclusions and Limitations of
this plan and must be medically necessary. You may be charged a Copayment
FIND A PROVIDER
Call or visit ACCESS DENTAL’s website to locate a
participating provider in your area.
Monday through Friday
8 a.m. to 6 p.m.
call 877.702.8800
visit premierlife.com
ADA Code
Description
Office Visit
D0120/0110
D0150
D0210
D0330
D0220
D0274
D1120
D1203
D1310
D1330
D1351
D1525
D1550
D2140
D2150
D2160
D2161
D2330
Preventive Services
Periodic Oral Exam
Comprehensive Exam
Full Mouth Series (FMX)
Panoramic X-rays
Periapical X-rays
Bitewings – four films
Prophylaxis (cleanings) – child
Fluoride Treatment – child
Nutritional counseling for control of
dental disease
Oral hygiene instructions
Sealant – per tooth
Space maintainer – removable –
bilateral
Recementation of space maintainer
Basic Services
Restorations – Amalgam (silver) 1
surface
Restorations – Amalgam (silver) 2
surfaces
Restorations – Amalgam (silver) 3
surfaces
Restorations – Amalgam (silver) fillings
four or more surfaces, primary or
permanent teeth
White composite filling, anterior 1
surface
WHA 1071 Pediatric Dental High 1.14
for missed appointments if you do not give the dental office at least 24 hours
notice of cancellation.
Copayment
ADA Code
$0
D2331
$0
$0
$0
$0
$0
$0
$0
$0
$0
D2332
D2390
D7140
D7210
D3310
$0
$0
$0
D3320
$0
D4341
D3330
$40
D2750
$40
D6210
$40
$40
D5110
D5211
$40
D8080/8090
Description
Basic Services continued
White composite filling, anterior 2
surfaces
White composite filling, anterior 3+
surfaces
White Composite Crown
Extraction, erupted tooth or exposed
root (elevation and/or forceps removal)
Surgical removal of erupted tooth
requiring elevation of mucoperiosteal
flap and removal of bone and/or
section of tooth
Root Canal Therapy – Anterior
(excluding final restoration)
Root Canal Therapy – Bicuspid
(excluding final restoration)
Root Canal Therapy – Molar (excluding
final restoration)
Periodontal scaling and root planing –
four or more teeth per quadrant
Major Services
Crowns – porcelain fused to high
noble metal
Bridges – pontic, high cast noble
metal
Complete denture – maxillary
Partial denture – resin base (including
any conventional clasps, rests and
teeth)
Comprehensive orthodontic treatment
of the adolescent dentition
Copayment
$40
$40
$40
$75
$135
$300
$365
$365
$75
$365
$365
$365
$365
$1,000