DentaQuest® Individual Pediatric High

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 (under age 19) None 50%

*Note: DentaQuest will pay the same percentage of the allowable charges for covered services received in and out of network. If you choose to see a non-contracting dentist (out of network), you will be responsible for the difference between the plan’s allowable charges (what contracting dentists receive for payment from DentaQuest) and the dentist’s usual and customary fees (what the dentist charges cash-paying patients).
 
Is there an out-of-pocket maximum?
For covered individuals under 19, the maximum out of pocket expense is $350 for each calendar year. The maximum family out of pocket expense is $700 for each calendar year.
 
Do I have out of network coverage?
Yes, DentaQuest will pay the same percentage for covered services received in and out of network. But if you choose to see a non-contracting dentist (out of network), you will be responsible for the difference between the plan’s allowable charges (what contracting dentists receive for payment from DentaQuest) and the dentist’s usual and customary fees (what the dentist charges cash-paying patients). This means you’ll save more by receiving care from a contracting dentist. 

 
Category / Procedure Benefit Limits DentaQuest pays
 
Diagnostic
Comprehensive oral exam Once every six months 100%
Periodic oral exam Once every six months 100%
Full mouth X-rays Once every 60 months 100%
Bitewing X-rays Once every six months 100%
Single tooth X-rays As needed 100%
Study models and casts Once every 60 months 100%

Preventive
Routine cleaning Once every 6 months 100%
Fluoride varnish application Two every 12 months 100%
Topical fluoride treatment Two every 12 months 100%
Space maintainers Not for the replacement of primary or permanent front teeth 100%
Sealants Less than age 19 – One sealant per tooth every 36 months 100%

Restorative
Silver fillings Covered 80%
White fillings (front teeth) Covered 80%
Temporary fillings Once per tooth 80%
Stainless steel crowns One per tooth in 60 months 80%

Major restorative
Crowns When teeth cannot be restored with fillings 50%
Replacement crowns Once every 60 months 50%
Implant Covered 50%

Endodontics (root treatments)
Root canal treatment Covered 50%
Vital pulpotomy Limited to baby teeth 50%

Periodontics (root treatments)
Periodontal cleaning Four in 12 months 80%
Scaling and root planing Subject to periodontal guidelines 50%
Periodontal surgery Must meet periodontal guidelines 50%

Dentures and bridges
Complete or partial dentures Once every 60 months 50%
Fixed bridges Once every 60 months 50%
Replacement dentures or
fixed bridges		 If they cannot be made serviceable once every
60 months		 50%
Rebase or reline dentures Once every 36 months 80%
Repair of dentures or fixed bridges Once every 12 months 80%
Adding teeth to existing dentures Covered 80%
Recementing fixed bridges Once every 12 months 80%

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

Orthodontics
Orthodontia When medically necessary 50%

Emergency dental care
Minor treatment - pain relief Covered 100%

Anesthesia
General anesthesia Allowed with covered surgical services only 80%