Benefits
Coinsurance
Plan pays:
In Network
100% Diagnostic & Preventive / 80% Basic / 50% Major
Out of Network
90% Diagnostic & Preventive / 70% Basic / 40% Major
Deductibles
$50 per adult (adult max $150)1
Annual Maximums
$1,500 per member
Waiting Periods
There are waiting periods for basic and major services2.
Receive Care From
Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (FL, GA, IL, IN, MI, MO, NC, NJ, OH, OR, WI) or any licensed dentist.
States Available
DC, DE, FL, GA3, IL, IN, MD, MI, MO, NC, NJ, OH, OR, PA, VA, WI
Preventive Care
Plan pays:
In Network
100%
Out of Network
90%
Services Include:
- Comprehensive Oral Exam
- Bitewing X-Rays (2 Sets)
- Full and Panoramic X-rays (100% covered in-network)
- Teeth Cleanings (Adult)
Basic Services
Plan pays:
In Network
80%
Out of Network
70%
Services Include:
- Amalgam Filling (silver)
- Composite Filling (white)
- Extraction, Erupted Tooth
Major Services
Plan pays:
In Network
50%
Out of Network
40%
Services Include:
- Crown (Porcelain/Metal)
- Bridges
- Complete Denture
- Relining of Dentures
- Periodontics (root planing and therapy)
- Endodontics (root canals)
- Oral Surgery (extraction of impacted teeth)
Orthodontics:
Orthodontia services are not covered.
Choice PPO Premium Kids
Enrolled dependents under the age of 19 will automatically be enrolled in our pediatric dental plan.
PLAN DETAILS
Explore Everything Included in the Dental Plan
Prevention Rewards
Get Cleanings. Get Rewarded!
With our Prevention Rewards Program, primary subscribers receive $20 for themselves and each enrolled family member who completes two cleanings in a calendar year with a participating dentist. It's simple, rewarding and included in every dental plan.*Shop Plans* The Discount Program does not include Prevention Rewards. Please see plan documents for full terms and conditions.
Vision Plan
Complement your dental coverage with a vision benefit or enroll in just a vision plan.
Explore plans to see if a vision benefit is available in your area.
Shop Plans - Deductibles apply to basic care and major restorative care.
- There are no waiting periods for diagnostic and preventive care. To be eligible for basic care, you must have completed 6 (six) months of continuous coverage. To be eligible for major restorative care, you must have completed 12 months of continuous coverage. Waiting period credit will be given for the length of time an insured was covered under each benefit classification under the current employer's prior dental coverage.
- Plans in Georgia: Out of Network coinsurance is the same as the in-network coinsurance. Note when using an Out of Network provider, members may incur any charges exceeding the allowed amount.
- Dominion National Internal Performance Report, 2024. Participating providers are subject to change.