DentaQuest® PPO
Individual Family Low

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 $100 per covered individual / $300 per family 40% under 19,
50% 19 and older
Complex dental services $100 per covered individual / $300 per family 40% under 19,
50% 19 and older
Orthodontics (under age 19) None 40% under 19,
no coverage 19 and older

Waiting Period: For Covered Individuals age 19 and older, Restorative and other Basic Services are subject to a six (6) month waiting period. Complex Dental Services are subject to a twelve (12) month waiting period.
 
*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.
 
What are my annual limits and maximums?
For covered individuals 19 and over, the total benefits are limited to a maximum of $1,000 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 will pay
  Under age 19 Age 19 and Older
Diagnostic
Comprehensive oral exam Under age 19 – Once every six months
Age 19 and older – Once every 60 months		 100% 100%
Periodic oral exam Once every six months 100% 100%
Full mouth X-rays Once every 60 months 100% 100%
Bitewing X-rays Once every six months 100% 100%
Single tooth X-rays As needed 100% 100%
Study models and casts Under age 19 – Once every 60 months 100% 100%

Preventive
Routine cleaning Once every six months 100% 100%
Fluoride varnish application Two every 12 months 100% 0%
Topical fluoride treatment Two every 12 months 100% 0%
Space maintainers Only for children under age 19 and not for the replacement of primary or permanent front teeth 100% 0%
Sealants Under age 19 – One sealant per tooth every 36 months 100% 0%

Restorative
Silver fillings Covered 40% 50%
White fillings (front teeth) Covered 40% 50%
Temporary fillings Once per tooth 40% 50%
Stainless steel crowns One per tooth in 60 months 40% 50%

Major restorative
Crowns When teeth cannot be restored with fillings 40% 50%
Replacement crowns Once every 60 months 40% 50%
Implant Covered for under age 19 40% 0%

Endodontics
Root canal treatment Covered 40% 50%
Vital pulpotomy Limited to baby teeth 40% 50%

Periodontics
Periodontal cleaning Under age 19 – Four in 12 months 40% 50%
Age 19 and older – One per 3 months
Scaling and root planing Subject to periodontal guidelines 40% 50%
Periodontal surgery Must meet periodontal guidelines 40% 50%

Dentures and bridges
Complete or partial dentures Once every 60 months 40% 50%
Fixed bridges Once every 60 months 40% 50%
Replacement dentures or fixed bridges If they cannot be made serviceable every 60 months 40% 50%
Rebase or reline dentures Once every 36 months 40% 50%
Repair of dentures or fixed bridges Once every 12 months 40% 50%
Adding teeth to existing dentures Covered 40% 50%
Recementing fixed bridges Once every 12 months 40% 50%

Oral surgery
Simple extractions Once per tooth per lifetime 40% 50%
Surgical extractions Once per tooth per lifetime 40% 50%

Orthodontics
Orthodontia Under age 19 – When medically necessary 40% 50%

Emergency dental care
Minor treatment - pain relief Covered 100% 50%

Anesthesia
General anesthesia Allowed with covered surgical services only 40% 50%