Download MyPriority Dental Pro Plan Schedule of Benefits

MyPriority Dental ProSM
Schedule of Benefits
MyPriority Dental ProSM Plan
Your Policy provides you with important information about your Dental Care benefits. This Schedule of Benefits provides you with
information about your costs when you receive Covered Services and the maximum limitations of your Dental Care benefits. Read the
entire Policy and Schedule of Benefits carefully.
See Section 6 of your Policy for detailed information about Covered and Non-Covered Services.
MAXIMUM ANNUAL BENEFIT
$1,500.00 is the combined maximum annual benefit per Member per Contract Year for all Covered Services in all classes.
MAXIMUM LIFETIME ORTHODONTIC SERVICES BENEFIT
$1,500.00 is the maximum benefit per Member per lifetime for all Covered orthodontic services.
WAITING PERIOD
Services in classes II, III and IV are subject to a waiting period of 180 days. See Section 7 of your Policy for additional information.
Services
Class I - Preventive Services
Dental Cleanings
Dental Exams
Fluoride treatment
Emergency Palliative Treatment
X-rays
Note: A bitewing set includes up to four
bitewing X-rays
Sealants
Benefits
100% Coverage
Limited to two per year
100% Coverage
Limited to two per year
100% Coverage
Limited to one treatment per year for Members under age 14
80% Coverage
80% Coverage
• One full set of bitewing X-rays Covered once every 24 months
• One full-mouth series (including bitewings and periapical films)
Covered once every 60 months
• One panoramic X-ray covered once every 84 months. Panoramic
X-rays taken with or without bitewings taken on the same day are
considered full panoramic X-rays.
80% Coverage
• Covered on first molars for Members under age 9
• Covered on second molars for Members under age 14
• Limit one sealant per tooth per lifetime
Class II – Minor restorative services
Services and supplies in this class are subject to a 180 day waiting period.
75% Coverage
Oral surgery services
Extractions and dental surgery, including
preoperative and postoperative care.
75% Coverage
Minor Restorative Services
Class III – Major restorative services
Services and supplies in this class are subject to a 180 day waiting period.
50% Coverage
Endodontics
One root canal treatment for a tooth involving one or more canals covered
once every 12 months
50% Coverage
Periodontic Surgery
Covered once every 36 months per quadrant
MyPriority Dental ProSM
Scaling and Root Planting
Includes curettage and polishing of teeth
Periodontal Maintenance
Can replace routine dental prophylaxis
Occlusal Adjustment
Occlusal Biteguard
Repair or Relining of Occlusal Biteguard
Bridges
Includes abutment, crowns and pontics (artificial
teeth to replace missing teeth)
Dentures
Repairs and Adjustments of Partial or
Complete Dentures
Tissue Conditioning for Dentures
Endosteal Implants
Note: Implant placement is for teeth numbered 2
through 15 and 18 through 31
Crowns
50% Coverage
Covered once every 36 months per quadrant
50% Coverage
50% Coverage
Limited adjustments are Covered up to five times in a 60-month period
50% Coverage
Covered once every 60 months
50% Coverage
Covered once every 60 months
50% Coverage
• Covered once every 60 months
• Pontics Covered for Members 16 years of age or older
50% Coverage
Covered once every 60 months
50% Coverage
• Covered once every 60 months
• Repairs Covered six months or more after initial delivery
• Adjustments allowed within six months of initial delivery
• Relining or rebasing Covered once every 36 months, per arch, six months
or more after initial delivery
50% Coverage
Covered once every 36 months
50% Coverage
Limited to one implant per tooth per lifetime for Members age 16 or
older. Member must be Covered under this Policy at time of Implant
placement.
50% Coverage
Covered once every 84 months for Members age 12 and older
Class IV – Orthodontic services
Services and supplies in this class are subject to a 180 day waiting period.
50% Coverage for Members under the age of 19
Orthodontic diagnostic procedures and
treatments, including braces
Note: We will consider charges for orthodontic
services incurred while Covered under the plan.
Coverage is for Members under the age of 19
only.
Filed in Michigan: 2014
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