Reviewing the PrimeCare Dental HMO Plan 106. This dental plan offers individual and family dental services. Dependants include your spouse, domestic partner and/or unmarried children who are 23 years of age and younger. Children 24 years of age and over are eligible only while the child is and continues to be both (1) incapable of sustaining employment by reason of developmental disability or physical challenge, and (2) is chiefly dependent upon the subscriber for support and maintenance, provided proof of incapacity and dependency is furnished to dental plan company. There are no deductibles and no yearly limits on services, and there are no claim forms to fill out.

Your savings are in place when you visit a network dentist. You just show up for your dental appointment and make your co-payment – what could be easier? The dentists must meet the Plan’s standard of quality and service. All have agreed to provide dental care at a low cost available only to its members. There is no waiting period for your dental services to begin, pre-existing dental conditions are covered subject to the plan limitations and best of all, the dental plan services start the first day of next month if ordered by the 25th of this month. Review the sample schedule below and see how easy it is for you or your entire family to enjoy these quality dental services.

Primecare Dental Limitations & Exclusions: Speciality co-payments vary by service area. Specialty referral pre-authorization required.

1. Full mouth X-rays: Limited to one (1) set every three (3) years unless diagnostically necessary.

2. Bitewing X-Rays: Two (2) sets in any twelve (12) month period unless diagnostically necessary.

3. Sealants: Limited to molars, up to the 16th birthday.

4. Fluoride: Up to the 18th birthday two(2) in any twelve (12) month period.

5. Delivery of removable prosthodontics includes adjustments within six months of delivery date of service.

6. Periodontal scaling and root planning: Limited to four (4) quadrants per twenty-four (24) consecutive months in combination with routine prophylaxis.

7. The copayments listed for endodontic procedures do not include the cost of the final restoration.

8. Panoramic x-rays: One (1) in any three (3) year period unless diagnostically necessary.

9. Prophylaxis: covered once every six consecutive months.

10. Reline of a complete or partial denture: One (1) per denture in any twelve (12) month period, unless dentally necessary.

11. Rebase of a complete or partial denture: One (1) per denture in any twelve (12) month period, unless diagnostically necessary.

12. Replacement of partial or full dentures are covered once per arch every five (5) years, except when they cannot be made functional through reline or repairs.

13. Complete or partial dentures are not to exceed one per arch in a five (5) year period unless necessary due to natural tooth loss where the addition to an existing partial or denture is not feasible. Primecare Dental Plan 106/2010

14. Treatment of malignancies, cysts, or neoplasm.

15. Periodontal grafting or splinting.

16. Extractions of impacted teeth with no radiographic evidence of pathology (disease). The removal of asymptomatic third molars is not a covered benefit unless pathology (disease) exists.

17. General anesthesia, analgesia, intravenous /intramuscular sedation or the services of an anesthesiologist.

18. Elective or cosmetic dentistry that are cosmetic in nature including, but not limited to bonding, bleaching teeth, personalization or dentures, posterior composites, porcelain veneers unless covered as a benefit.

19. Orthodontic treatment in process, or extractions for orthodontic purposes.

20. Procedures, appliances or restorations whose primary purpose is to change the vertical deminsion of occlusion, correct congenital development or medically induced dental disorders including but not limited to treatment of myofunctional, myoskeletal, or tempormandibular joint disorders unless otherwise specifically listed as a covered benefit on the plans schedule of benefits.

21. Precision attachments, stress breakers, magnetic retention or overdenture attachments.

22. Cephalometric x-rays, except when performed as part of the orthodontic treatment plan and records for a covered course of comprehensive orthodontic treatment.

23. Inlays, onlays, crowns or fixed bridges started, but not completed, prior to the Member’s eligibility to receive benefits under this Plan.

24. (Inlays, onlays, crowns or fixed bridges are considered to be started when the tooth or teeth are prepared, and completed when the final restoration is permanently cemented).

25. Dentures or orthodontic treatment started prior to the Member’s eligibility to receive benefits under this Plan.

26. (Dentures are considered to be started when the impressions area taken. Orthodontic treatment is considered to be started when the teeth are banded).

27. Replacement of lost or stolen prosthetics or appliances including crowns, bridges, partial dentures, full dentures, and orthodontic appliance.

28. Any treatment requested, or appliances made, which are either not necessary for maintaining or improving dental health, or are for cosmetic purposes unless otherwise covered as a benefit.

29. Any procedure or treatment unable to be performed in the dental office due to the general health or physical limitation of the member.

30. Dental implants and services associated with the placement of implants, prosthodontic restoration of dental implants, and specialized implant maintenance services.

31. Oral surgery requiring the setting of bone fractures or dislocations, Hospitalization , Out- patient services, Ambulance services, Durable Medical Equipment, Mental Health services, Chemical dependency services, Home Health services.

32. Dispensing of drugs supplied in a dental office.

33. Any condition for which benefits of any nature are recovered or found to be recoverable, whether by adjudication or settlement, under any Worker’s Compensation or Occupational Disease Law, even though the Member fails to claim his or her rights to such benefit.

34. Any service or procedure associated with the placement, prosthodontic restoration or maintenance of a dental implant and any incremental charges to other covered services as a result of the presence of a dental implant.

35. Root canal treatment started, but not completed, prior to the Member’s legibility to receive benefits under this Plan.

36. (Root canal treatment is considered to be started when the pulp chamber is opened, and completed when the permanent root canal filling material is placed.)

37. Coverage is up to twenty-four (24) months of comprehensive orthodontic treatment. If treatment goes beyond twenty four (24) months is necessary, the Member will be responsible for additional charge for each additional month of treatment based up to the participating Orthodontic Specialist Dentist’s contracted fee.

38. If a Member transfer to another Participating Orthodontist after comprehensive orthodontic treatment has been started the Member will be responsible for any additional costs associated with the change in orthodontist and subsequent treatment.
Orthodontic Limitations and Exclusions

The Plan covers orthodontic services as listed under Covered Dental Services, limited to one course of treatment in lifetime. Orthodontic services are not covered if comprehensive treatment begins before the Member is eligible for benefits under the Plan. If a Member’s coverage terminates after the fixed banding appliances are inserted, the Participating Orthodontist Specialist Dentist After the termination date, the Member will be responsible for any additional monthly amounts. Orthodontic treatment shall only be provided by a member of the Plan orthodontic panel.

The following are exclusions of orthodontic coverage

1. Re-treatment of orthodontic cases, or changes in orthodontic treatment necessitated by any kind of accident.

2. Replacement or repair of orthodontic appliances damaged due to the neglect of the Member.

3. Tracings, records, study models, x-rays and photographs.

4. Initial examination, consultation, diagnosis, treatment planning, retention appliances and related visits.

5. Cephalometric x-rays.

6. Lost or broken appliances.

7. Myofunctional therapy.

8. Surgical procedures such as extractions of teeth strictly for the purpose of orthodontia.

9. Any jaw surgical procedure related to orthodontia.

10. Dental services of any nature, performed in hospital or convalescent home or anywhere outside the office or Plan provider.

11. Dispensing of drugs not normally supplied in an orthodontic practice.

12. Treatment related to Temporomandibular Join Dysfunction or hormonal imbalances.

Primecare Cancellation Policy

You may cancel your policy at any time by notifying Member Services in writing. For enrollment of a continuous period of 12 months may cancel your policy only within the first 30 days after enrollment and receive a full refund provided that you have not used your benefits during that period.