Dental
Dental DHMO Plan
DHMO Plan Document | Blue Shield
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Blue Shield Dental offers a comprehensive DHMO plan with Orthodontia coverage. The DHMO plan has a set copay schedule for every treatment covered by the plan. The patient charge schedule applies to in-network general dentists and specialists when an appropriate authorized referral is made to a Network Specialty dentist such as an Oral Surgeon, Periodontist and Endodontist. Prior authorization for all specialty except Pediatric dentist. Meissner Mfg. Co., Inc. pays 100% of your enrolled premium for DHMO employee-only dental coverage if you elect this coverage.
| MAXIMUM THE CARRIER WILL PAY | |
|---|---|
| Annual Maximum | Unlimited |
| FREQUENCIES | |
| Cleaning | Once every 6 months |
| Exam | Once every 6 months |
| DENTAL COVERAGE | |
| Cleanings | 0% |
| Exams | 0% |
| X-Rays | 0% |
| Sealants | 0% |
| Fillings | Copays Vary |
| Simple Extractions | Copays Vary |
| Root Canal | Copays Vary |
| Periodontal Gum Disease | Copays Vary |
| Oral Surgery | Copays Vary |
| Crowns | Copays Vary |
| Orthodontia (adult & children) | $1,500 / $1,200 |
| Orthodontia Maximum Age | Dependents are covered up to age 26 |
PREMIUM PER PAYCHECK |
|
|---|---|
| Employee Only | $0.00 |
| Employee + Spouse | $10.62 |
| Employee + Child(ren) | $14.12 |
| Family | $21.18 |
Dental DPPO Plan
Bronze DPPO 1500-MAC Plan Document | Blue Shield
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| DEDUCTIBLE | IN-NETWORK | OUT-NETWORK |
|---|---|---|
| Single | $50 | $50 |
| Family | $150 | $150 |
| MAXIMUM THE CARRIER WILL PAY | ||
| Annual Maximum | $1,500 | $1,500 |
| FREQUENCIES | ||
| Cleaning | Once every 6 months | |
| Exam | Once every 6 months | |
| DENTAL COVERAGE | ||
| Cleanings | 0% | 20% |
| Exams | 0% | 20% |
| X-Rays | 0% | 20% |
| Sealants | 0% | 20% |
| Fillings | 20% | 40% |
| Simple Extractions | 20% | 40% |
| Root Canal | 20% | 40% |
| Periodontal Gum Disease | 20% | 40% |
| Oral Surgery | 50% | 50% |
| Crowns | 50% | 50% |
| Dentures | 50% | 50% |
| Bridges | 50% | 50% |
| Implants | 50% | 50% |
| Orthodontia | Not Covered | Not Covered |
| OUT OF NETWORK EXPLANATION | ||
Your insurance carrier will pay the out of network dentist the same rate they |
||
PREMIUM PER PAYCHECK |
|
|---|---|
| Employee Only | $6.18 |
| Employee + Spouse | $22.89 |
| Employee + Child(ren) | $31.25 |
| Family | $46.29 |