Individual Dental Plan

Oral Health And Overall Health

Your oral health says a lot about your overall health. Regular dental checkups are necessary to maintain your good health and the good health of your family. The human mouth teems with bacteria, most of which is normally kept in check by daily brushing and flossing. When harmful bacteria grows out of control, it causes tooth decay, gum disease and other problems. During a preventive Preventive Care – Measures taken to prevent illness or injury, rather than to treat it. Preventive care can include immunizations, screening tests, and examinations to test for specific conditions based on an individual's family history. exam or dental checkup, dentists can detect much more than cavities and broken fillings. Dentists spot oral characteristics of certain medical conditions – from osteoporosis and diabetes to heart and kidney disease – before they become serious and costly to treat.

Take care of your oral health to help maintain your overall health. A ConnectiCare Dental plan can help you do that.

Dental Plan Benefit Summary for ConnectiCare SOLO Subscribers


$25 Deductible, 100%/0%/0%, Unlimited Maximum, No Ortho Coverage


Rates displayed are quoted rates only. Plans and rates are subject to approval by the Connecticut Insurance Department. Final rates are subject to change based on medical history, federal and state regulations, and ConnectiCare's underwriting guidelines.



Covered Dental Services
Participating
Provider
(In-Network
Level Of Benefits)
Non-Participating
Provider
(Out-of-Network
Level Of Benefits)*
Care Category Procedure Code Description By Illustration, Not By Limitation
100% 100% Diagnostic 00100-00199
00331-00999
Oral examination, diagnostic casts.
100% 100% X-Rays 00200-00330 Complete mouth x-rays, periapical x-rays, bitewing x-rays, panoramic x-rays.
100% 100% Preventive Preventive Care – Measures taken to prevent illness or injury, rather than to treat it. Preventive care can include immunizations, screening tests, and examinations to test for specific conditions based on an individual's family history. 01000-01999 Prophylaxis, fluoride, applications, space maintainers.
100% 100% Restorative** 02000-02399 The treatment of tooth decay by the use of amalgam and/or composite restorations.
0% 0% Restorative-Crowns** 02400-02999 The use of gold, semiprecious, or nonprecious metals to restore a tooth or teeth which cannot be restored with amalgam or composite restorations.
0% 0% Endodontics** 03000-03999 The treatment of the diseases of the nerve of the tooth.
0% 0% Periodontics 04000-04999 The treatment of the supporting tissues of the teeth, gums, and underlying bone, with either surgical or non surgical procedures (where applicable).
0% 0% Prosthetics - Removable** 05000-05399
05600-05899
The replacement of missing teeth by the use of a removable appliance.
0% 0% Prosthetics - Adjustment** 05400-05799 The repair or modification of existing removable and/or fixed appliances so that they can continue to be serviceable.
0% 0% Prosthetics - Fixed, Implants** 06000-06999 The use of gold, semiprecious, presious metal or implant to replace a missing tooth or teeth, which cannot otherwise be replaced with a removable appliance.
0% 0% Extractions** 07000-07219
07250-07999
The extractions, either simple or surgical, of either a single tooth or multiple teeth, the shaping of bone ridges, the removal of a tooth end abscess, etc.
0% 0% Bony Impactions** 7220-07249 The surgical removal of teeth partially or fully covered by bone.
0% 0% Orthodontics** 08000-08999 The straightening of teeth for dental health reasons.
0% 0% General Services** 09000-09999 All other adjunctive general services as coded in the American Dental Association (ADA) Current Dental Terminology, which are not included in the specific categories listed, that are covered services.
Deductibles and Maximums
Participating
Provider
(In-Network
Level Of Benefits)
Non-Participating
Provider
(Out-of-Network
Level Of Benefits)*
Unlimited Unlimited Annual Maximum Per Individual
$25.00 $25.00 Annual Deductible Per Individual
$0.00 $0.00 Orthodontic Lifetime Maximum Per Individual




Benefit year effective date is the Subscriber's Effective Date
As used herein, "Annual" means the benefit year in which dental care services are performed.

* For those subscribers electing to be served by a non-participating provider; submitted claims will be processed at any time during the benefit year and reimbursements will be made at the level of coverage listed under "Non-Participating Provider(Out-Of-Network Level of Benefits)" and in amounts up to the schedule of allowances paid to participating provider. Payments will be limited to the individual annual maximum listed above or that portion of the individual annual maximum, which may be remaining if care had previously been provided during the benefit year by a participating provider, subject to the plan’s deductibles and standard exclusions and limitations.

** Care Category (ies) of coverage the deductible applies to.

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