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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

Treatment to reduce trauma and restorative services is limited to dental implants only when the result of accidental injury to sound natural teeth and tissue that are viable, functional and free of disease. Oral surgery is covered when medically necessary as a direct result of injury, tumors or cysts. Oral surgery includes but is not limited to reduction of fractures and dislocation of the jaws, external incision and drainage of cellulitis, incision of accessory sinuses, salivary glands or ducts, excision of exostosis of jaws and hard palate and frenectomy. Treatment must be initiated within 60 days of accident. No coverage for dental care, including oral surgery, as a result of poor dental hygiene. Extractions of bony or partial bony impactions are excluded.

Restorative services limited to dental implants when needed as a result of cancerous or non-cancerous tumors and cysts, cancer and post-surgical sequelae.

The administration of general anesthesia, monitored anesthesia care and hospital charges for dental care are covered for children younger than 5 years, the severely disabled, or a person with a medical or behavioral condition that requires hospitalization when provided in a network or non-network hospital or surgical center.

Preauthorization by medical plan is required.


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