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Dental Summary of Benefits: Licensed Sub

ODS Dental Plan

Plan Type: Fee for Service Coverage
Deductible $25.00
Annual Maximum $1,500.00
Preventive Care
  • Oral Examinations
  • Prophylaxis
  • Topical Fluoride Application
  • Space Maintainers
  • Sealants
  • Periapical and Bitewing X-rays
 100%
Deductible waived
Restorative Services
  • Extractions
  • Fillings (posterior teeth paid to amalgam fee)
  • Palliative Emergency Treatment
  • Oral Surgery
  • Endodontics
  • Periodontic Services
  • Inlays (amalgam reimbursement fee)
 80%
Major Dental Care
  • Onlays
  • Crowns
 80%
Prosthodontic Services
  • Implants
  • Bridges
  • Dentures
  • Partial Dentures
  • Temporary Partial Denture (flipper or stayplate w/in 2 months of extraction)
50%
Oral Health Total Health
  • Diabetics eligible for additional prophylaxis (cleanings) –requires proof of condition from provider
  • Pregnant women eligible for additional prophylaxis (cleanings) in third trimester

100%
Deductible waived

General Exclusions for ODS Dental Plans

  • Services that are not necessarily dental care.
  • Gnathologic recordings.
  • Oral study models.
  • Educational programs.
  • Services paid under Medical contract.
  • Services provided by a member of your immediate family.
  • Charges over the allowed amount.
  • Benefits not stated.
  • Periodontal splinting.
  • Services covered under workers' compensation or employers' liability laws and services covered by any federal, state, county, municipality or other government agency, exceopt Medicaid.
  • Service related conditions (armed forces of any country or from an insurrection)
  • Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing teeth.
  • Services started prior to or after the date the individual became eligible for services under the program.
  • Hypnosis, prescribed drugs, premedications or analgesia (e.g. nitrous oxide) or any other euphoric drugs.
  • Fee for writing a prescription for medications or filing out claims forms.
  • Hospital costs or any additional fees charged by the dentist because the patient is hospitalized.
  • General anesthesia and/or IV sedation except when administered by a dentist in conjunction with covered oral surgery in his or her office.
  • Plaque control and oral hygiene or dietary instructions.
  • Experimental or investigational procedures.
  • Missed or broken appointments.
  • Orthodontic services (if district selects no orthodontia plan).
  • Services and supplies for cosmetic reasons.
  • Claims submitted more than 15 months after the date of rendition of the services.
  • Periodontal charting.
  • Services that are not established as necessary.
  • Services that are inappropriate with regard to standards of good dental practice.
  • Services with poor prognosis.
  • Local delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue.
  • Third party liability.
  • Motor Vehicle Coverage and other insurance liability.
  • Work-Related Conditions Care of inmates.
  • Temporomadibular Joint and related problems.
  • Missing teeth.
  • Appliances or restorations.
  • Take-Home Medicines and Supplies
  • Temporary dentures.
  • All other services or supplies, not specifically covered.
  • Repair of dentures and bridges.
  • Bruxism.
  • Splints and nightguards.
  • Apicodectomy.
  • ViziLite.
  • Taxes.
  • Services performed on the tongue, lip, or cheek.
  • Removal of implants.
  • Congenital malformations.

Full Dental Plan Book: Plan 4 (no orthodontia)