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Option I |
Option II
in network/out of network |
Option III
in network/out of network |
| |
|
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| Office Visit |
No charge |
100% / 90% |
100% / 80% |
| |
|
| |
Oral Examination
(every 6 months) |
No charge |
100% / 90% |
100% / 80% |
| |
|
| |
| Tooth Extraction |
No charge |
80% / 70% |
50% / 40% |
| |
|
| |
Prophylaxis
(cleaning - every 6 months) |
No charge |
80% / 70% |
50% / 40% |
| |
|
| |
Crown - porcelain, base
metal
(per tooth) |
$200 |
50% / 40% |
50% / 40% |
| |
|
| |
| Molar Root canal |
$185 |
80% / 70% |
50% / 40% |
| |
|
| |
Bridge - porcelain, base metal
(per tooth) |
$200 |
100% / 90% |
50% / 40% |
| |
|
| |
| Please see schedule of benefits for a complete list of benefits,
limitations and exclusions. |
About Fillings
With the improvement in technology and increase in strength of resin
fillings, many dentists recently have begun to provide resin fillings
exclusively in their office, replacing the use of the traditional amalgam
(commonly known as silver) fillings. Each dentist in our network is an
independent practitioner and chooses the materials that, in the best
judgment of the dentist, will restore the patient to optimal oral health.
When selecting a network dentist please recognize that not all
participating providers perform all services or recommend all types of
treatments, including amalgam fillings. Please discuss with your dentist
the range of services provided by the dentist prior to the initiation of
treatment.
Using a Pedodontist
Every family has individual needs, and one dentist may not satisfy all
of them. With Option I, you have the choice to select the dentist that
best satisfies the need of each individual. Pedodontists are available to
children without the need of a referral. Pedodontists only treat children.
So, you have the option to select a Pedodontist for your child or you may
choose to have your child see a General Dentist. The choice is yours, and
CompBenefits allows you to determine what is the best choice for you and
your family. If you choose Option II or III, you must file a claim form
for reimbursement of services. PPO participating providers will file a
claim for you for reimbursement or you may also choose to file a claim.
Orthodontics
Option I and Option II are your choices for Orthodontic coverage with
CompBenefits.
Option I allows coverage for both adults and children. Co-payments under
this Option are set at $1400 for children and $1950 for adults with a $225
start up fee for a pre-orthodontic treatment analysis. These prices are
based on 24 months of orthodontic treatment. Cases that require more than
24 months are subject to additional charges. With participating
Orthodontists only, cases already under treatment are eligible for
discounts.
Option II allows coverage for dependent children 18 years of age or
younger. The deductible for in or out of network services is $50 with a
maximum of 3 per family. The reimbursement amount for covered services is
set at 50% both in and out of network. There is also a 12 month waiting
period before eligibility.
Continuation of Treatment for Orthodontics
If you or your dependent is currently in active orthodontic treatment,
CompBenefits will provide benefits for the continuation of the treatment,
without a break in coverage.
If you choose Option II, you or your dentist must submit a copy of the
original treatment plan and the total dollar amount paid by the previous
carrier for orthodontic treatment. We will deduct any amount paid by the
previous carrier from the maximum allowed amount. The combined
reimbursement paid by both carriers will not exceed the lifetime maximum
orthodontic allowance for the plan.
If you choose Option I you will be required to pay your co-payment and
CompBenefits will pay any additional fees. The time remaining on the
treatment plan will determine the level of reimbursement that would need
to be negotiated between the provider and CompBenefits.
