Pediatric Dental Benefits

Pediatric Dental Benefits 2016-12-14T18:07:05+00:00

Pediatric Dental Benefits

New for 2017, all Health Connector plans include pediatric dental coverage. Use the information on this page to quickly find information about pediatric dental benefits each plan covers and costs. Please remember to check your plan’s Summary of Benefits and Coverage for more information.

Click the name of your new health or dental insurer to skip down the page and learn more

Ambetter from CeltiCare Health logo

Ambetter from CeltiCare Health

The following pediatric dental benefits apply to all 2017 health plans from Ambetter from CeltiCare Health:

Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? The maximum out-of-pocket is $350.
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits, but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $50 per member, deductible does not apply to preventive and diagnostic services (Deductible applies to both In-Network and Out-of-Network benefits combined)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia and Type 3 services. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
Deductible, then 25% co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
Deductible, then 50% co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
Deductible, then 50% co-insurance Not Covered
Blue Cross Blue Shield of Massachusetts logo

Blue Cross Blue Shield of Massachusetts (BCBSMA)

The following Dental Blue Pediatric Essential Benefits apply to all 2017 health plans from Blue Cross Blue Shield of Massachusetts:

Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? The maximum out-of-pocket is $350 per child $700 for 2 or more children
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $50 per member, deductible does not apply to preventive and diagnostic services (Deductible applies to both In Network and Out of Network benefits combined)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Deductible then, 20% co-insurance
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
Deductible, then 25% co-insurance Deductible then, 45% co-insurance
Type 3 Services
Major Restorative (dentures and crowns)
Deductible, then 50% co-insurance Deductible then, 70% co-insurance
Medically Necessary Orthodontia
(requires prior authorization)
Deductible, then 50% co-insurance Deductible then, 70% co-insurance
BMC Healtnet Plan logo

Boston Medical Center HealthNet Plan (BMCHP)

The following pediatric dental benefits apply to all 2017 health plans from Boston Medical Center HealthNet Plan:

Who do these benefits cover? All members age 21 and younger
What is the most I’ll have to pay for dental services in the plan year? The Maximum out of pocket limit of $350 is the most you could pay during a coverage period for your share of the cost of a covered dental service. This limit helps you plan for dental expenses. You will have to continue to pay for medical services until you reach what is left of the maximum out of pocket limit. After you reach your out-of-pocket maximum, the health plan pays for all covered services.
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $50 per member, deductible does not apply to preventive and diagnostic services
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
Deductible, then 25% co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
Deductible, then 50% co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Fallon Health logo

Fallon Health

Click on a plan name below to see pediatric dental benefits that apply to the 2017 individual and family health plan from Fallon Health:

Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $750 / $1,500  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $0
What happens after I reach my maximum out-of-pocket? Not applicable
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $1,500 / $3,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150/$14,300 (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150/$14,300 (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
20% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $6,850 / $13,700  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $3,000 / $6,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $5,000 / $10,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $3,000 / $6,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the plan pays for all dental  services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $3,000 / $6,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $5,000 / $10,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $3,000 / $6,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Harvard Pilgrim Health Care logo

Harvard Pilgrim Health Care

Click on a plan name below to see pediatric dental benefits that apply to the 2017 individual and family health plan from Harvard Pilgrim Health Care:

Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $5,250 / $10,500  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% 50%
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% 50%
Type 3 Services
Major Restorative (dentures and crowns)
50% 50%
Medically Necessary Orthodontia
(requires prior authorization)
50% 50%
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $6,400 / $12,800  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% 50%
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% 50%
Type 3 Services
Major Restorative (dentures and crowns)
50% 50%
Medically Necessary Orthodontia
(requires prior authorization)
50% 50%
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% 50%
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% 50%
Type 3 Services
Major Restorative (dentures and crowns)
50% 50%
Medically Necessary Orthodontia
(requires prior authorization)
50% 50%
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $5,000 / $10,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% 50%
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% 50%
Type 3 Services
Major Restorative (dentures and crowns)
50% 50%
Medically Necessary Orthodontia
(requires prior authorization)
50% 50%
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $3,000 / $6,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% 50%
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% 50%
Type 3 Services
Major Restorative (dentures and crowns)
50% 50%
Medically Necessary Orthodontia
(requires prior authorization)
50% 50%
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% 50%
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% 50%
Type 3 Services
Major Restorative (dentures and crowns)
50% 50%
Medically Necessary Orthodontia
(requires prior authorization)
50% 50%
Health New England logo

Health New England (HNE)

The following pediatric dental benefits apply to all 2017 individual and family health plans from Health New England:

Who do these benefits cover? All members under age 19 (covered until the end of the plan year in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year?
  • In-Network Out-of-Pocket Maximum: $350 per member
  • Out-of-Network Out-of-Pocket Maximum: None
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first?
  • No Deductible for Preventive & Diagnostic Services.
  • $50 Individual Deductible for Basic and Major Services.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge 20% Co-insurance
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance 45% Co-insurance
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance 70% Co-insurance
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance 70% Co-insurance
Minuteman Health logo

Minuteman Health

Click on a plan name below to see pediatric dental benefits that apply to the 2017 individual and family health plan from Minuteman Health:

Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $3000/$6000 (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% Co-insurance Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $6000/$12,000 (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% Co-insurance Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $6,000/$10,000 (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $1,000/$2,000 (applies to Medical, Behavioral Health, and some dental services)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% Co-insurance after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150/$14,300 (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $2,000/$4,000 (applies to Medical, Behavioral Health, and some dental services)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% Co-insurance after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150/$14,300 (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $2,000/$4,000 (applies to Medical, Behavioral Health, and some dental services)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% Co-insurance after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150/$14,300 (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $2,500/$5,000 (applies to Medical, Behavioral Health, and some dental services)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
  • Periodic oral exams: $15 Copay + 50% Coinsurance after deductible
  • All other services: 50% Coinsurance after deductible
Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150/$14,300 (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $2,750/$5,500 (applies to Medical, Behavioral Health, and some dental services)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
  • Periodic oral exams: $15 Copay + 50% Coinsurance after deductible
  • All other services: 50% Coinsurance after deductible
Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150/$14,300
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the dental plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $7,150/$14,300
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
No charge after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
No charge after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
No charge after deductible Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $0
What happens after I reach my maximum out-of-pocket? Not applicable.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There are no dollar limits but benefit limits may apply to certain services.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
No charge Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
No charge Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
No charge Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $750 / $1,500  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the plan pays for all dental  services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% Co-insurance Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $1,500 / $3,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the plan pays for all dental  services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
50% Co-insurance Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
50% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Neighborhood Health Plan logo

Neighborhood Health Plan (NHP)

Click on a plan name below to see pediatric dental benefits that apply to the 2017 individual and family health plan from Neighborhood Health Plan:

Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $0
What happens after I reach my maximum out-of-pocket? Not applicable.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
No Charge Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
No Charge Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
No Charge Not Covered
Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $750 / $1,500  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
No Charge Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
5% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
5% Co-insurance Not Covered
Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $1,500 / $3,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
No Charge Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
10% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
10% Co-insurance Not Covered
Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $3,000 / $6,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $3,000 / $6,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $500/$1,000 Deductible (applies to Medical, Behavioral Health, and some dental services)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
Deductible, then 25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
Deductible, then 50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
Deductible, then 50% Co-insurance Not Covered
Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $5,000 / $10,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $1,000/$2,000 Deductible (applies to Medical, Behavioral Health, and some dental services)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
Deductible, then 25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
Deductible, then 50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
Deductible, then 50% Co-insurance Not Covered
Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $6,850 / $13,700  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $2,000/$4,000 Deductible (Deductible applies to Medical, Behavioral Health, prescription drugs, and dental)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
Deductible, then 25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
Deductible, then 50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
Deductible, then 50% Co-insurance Not Covered
Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $2,000/$4,000 Deductible (applies to Medical, Behavioral Health, and some dental services)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
Deductible, then 25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
Deductible, then 50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
Deductible, then 50% Co-insurance Not Covered
Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? $2,750/$5,500 Deductible (applies to Medical, Behavioral Health, and some dental services)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
Deductible, then 25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
Deductible, then 50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
Deductible, then 50% Co-insurance Not Covered
Tufts Health Plan logo

Tufts Health Plan – Direct

Click on a plan name below to see pediatric dental benefits that apply to the 2017 individual and family health plan from Tufts Health Plan – Direct:

Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $3,000 / $6,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $3,250 / $6,500  (The dental services are integrated with the out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? All dental services are subject to the medical deductible:
$500 (individual) / $1,000 (family)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $5,000 / $10,000  (The dental services are integrated with the out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? All dental services are subject to the medical deductible:
$1,000 (individual) / $2,000 (family)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? All dental services are subject to the medical deductible:
$2,000 (individual) / $4,000 (family)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? All dental services are subject to the medical deductible:
$2,200 (individual) / $4,400 (family)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? All dental services are subject to the medical deductible:
$2,200 (individual) / $4,400 (family)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? All dental services are subject to the medical deductible:
$2,750 (individual) / $5,500 (family)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance after deductible Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $1,500 / $3,000  (The dental services are integrated with the out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
No Charge Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
No Charge Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
No Charge Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $750 / $1,500  (The dental services are integrated with the out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
No Charge Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
No Charge Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
No Charge Not Covered
Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $0
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
No Charge Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
No Charge Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
No Charge Not Covered
Who do these benefits cover? All members under age 19 (covered through the end of the month in which the member turns 19)
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? All dental services are subject to the medical deductible:
$7,150 (individual) / $14,300 (family)
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge after deductible Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
No Charge after deductible Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
No Charge after deductible Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
No Charge after deductible Not Covered

Tufts Health Plan – Premier

Click on a plan name below to see pediatric dental benefits that apply to the 2017 individual and family health plan from Tufts Health Plan – Premier:

Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $3,000 / $6,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year?  $5,000 / $10,000  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $7,150 / $14,300  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? There is no deductible for this plan.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
50% Co-insurance Not Covered
Who do these benefits cover?  All members age 19 and younger
What is the most I’ll have to pay for dental services in the plan year? $6,550 / $13,100  (The dental services are integrated with the  out-of-pocket maximum for medical benefits)
What happens after I reach my maximum out-of-pocket? After you reach your out-of-pocket maximum, the health plan pays for all covered services.
Is there a yearly limit to the amount my plan will pay for dental services? There are no dollar limits but benefit limits may apply to certain services.
Does the dental plan pay for services right away, or do I have to pay something first? Members on this H.S.A.-qualified plan have a combined deductible (medical, Rx, and pedi-dental) of $3,300 / $6,600 that will apply to non-preventive dental services.
Are there waiting periods for certain services? Prior authorization is required for medically necessary orthodontia. You must have plan approval prior to having services rendered in order for services to be covered.
You Pay
In-Network
You Pay
Out-of-Network
Type 1 Services
Preventive and Diagnostic services (oral exams, x-rays, and cleanings)
No Charge Not Covered
Type 2 Services
Basic restorative (fillings, extractions, root canal treatments)
Deductible, then 25% Co-insurance Not Covered
Type 3 Services
Major Restorative (dentures and crowns)
Deductible, then 50% Co-insurance Not Covered
Medically Necessary Orthodontia
(requires prior authorization)
Deductible, then 50% Co-insurance Not Covered