DentaQuest®
Individual Family Preventive

This plan is available on the Federally Facilitated Marketplace (FFM) in the following states: AZ, FL, GA, IL, IN, LA, MO, OH, PA, TN, TX, VA.

Coverage Summary

Coverage type Calendar year deductible DentaQuest will pay
 
Diagnostic and preventive services None 100%
Restorative and other basic services $50 per covered individual / $150 per family 80%
Complex dental services $50 per covered individual / $150 per family 50%
Orthodontics (up to age 19 only) None 50%


Is there an out-of-pocket maximum?
For members under 19, the maximum out of pocket expense is $350 for each calendar year. A family with two or more members under 19 will have an aggregate maximum out of pocket expense of $700 per calendar year.

Do I have out of network coverage?
There is no out of network coverage. If you see a non-participating dentist you will be responsible for the entire cost of the services you receive

 
Category / Procedure Benefit limits DentaQuest will pay
 
Diagnostic
Comprehensive oral exam Once every six months 100%
Periodic oral exam Twice every calendar year 100%
Full mouth X-rays Once every 60 months 100%
Bitewing X-rays Twice every calendar year 100%
Single tooth X-rays As needed 100%
Study models and casts Once every 60 months 100%

Preventive
Routine cleaning Once every six months 100%
Fluoride varnish application Once every six months 100%
Space maintainers Only for premature loss of teeth, once per year 100%
Sealants One per tooth 100%

Restorative
Silver fillings One filling for each tooth surface per year 80%
White fillings (front teeth) One filling for each tooth surface per year – front teeth only 80%
Temporary fillings Covered 80%
Stainless steel crowns Once every 24 months for baby teeth only 80%

Major restorative
Crowns Covered 50%
Replacement crowns Once each 36 months per tooth 50%
Repair or recement crowns Covered 80%
Temporary crowns Covered 50%
Veneers When medically necessary 50%

Endodontics (root treatments)
Root canal treatment Covered 50%
Vital pulpotomy Limited to baby teeth 50%
Root surgery Once per tooth per lifetime 50%

Periodontics (gum treatments)
Periodontal cleaning Subject to periodontal guidelines 50%
Scaling and root planing Subject to periodontal guidelines 50%
Removal of calculus to aid in diagnosis Once per year 50%
Removal of diseased gum tissue Once per two years per quadrant 50%
Reshaping of diseased bone Once per quadrant per 36 months 50%
Treatment to stabilize tooth 50%

Dentures and bridges
Complete or partial dentures Once each 60 months 50%
Fixed bridges Once every 60 months 50%
Temporary partial dentures Replace any six upper or lower front teeth, installed immediately following loss of teeth
Replacement of permanent teeth for children under 16 years		 50%
Replacement dentures or fixed bridges Covered 50%
Rebase or reline dentures Once every 24 months 80%
Repair of dentures or fixed bridges Covered 80%
Adding teeth to existing dentures Covered 80%
Recementing fixed bridges Covered 80%

Oral surgery
Simple extractions Once per tooth per lifetime 80%
Surgical extractions Once per tooth per lifetime 50%

Orthodontics
Orthodontia When medically necessary 50%

Emergency dental care
Minor Pain relief treatment Covered 80%

Anesthesia
General anesthesia Allowed with covered surgical services only 80%

Local anesthesia
80%