Plan Information

Dominion Dental Access PPO 1
Plan Features

The following fees apply only when services are performed by your selected Dominion general dentist. The below fees do not apply when performed by a Program Specialist (with the exception of Orthodontics). Program Specialist, if available, will reduce fees 25% from Usual, Customary, and Reasonable (UCR) fees, except in the State of Delaware. In Delaware, Program Specialists will provide a reduction from their UCR that will vary between specialists.

For a full detail, please download your Schedule of Benefits. Adult and Pediatric: D.C., Delaware, Maryland, Pennsylvania, Virginia

Access PPO 1

* Year 1 benefits apply during the subscribers first 12 months of continues coverage. Year 2 benefits apply during the subscriber’s second 12 months of continues coverage. Year 3 benefits apply during the subscriber’s third 12 months of continues coverage.

Out-of-network dentists can bill you for charges above the amount covered by your Dominion Dental plan. To ensure you do not receive additional charges, visit a dentist in the Dominion Dental PPO network.

  In Network
  Year 1* Year 2* Year 3*
Preventive Dental Benefits:
Routine exams, teeth cleanings (2), bitewing X-rays.
Plan Pays 100%
Basic Dental Benefits
Fillings, X-rays, simple extractions.
Plan Pays 40% Plan Pays 60% Plan Pays 80%
Major Dental Benefits
Oral surgery (surgical extractions & impactions), endodontics, periodontics, crowns, bridges, dentures.
Plan Pays 15% Plan Pays 25% Plan Pays 50%
Dental Deductible
Per calendar year, per insured person for Preventive, Basic, & Major Services.
$50
Maximum Dental Benefits
Dental Benefits Per calendar year, per insured person.
$1,000
Access PPO 1

* Year 1 benefits apply during the subscribers first 12 months of continues coverage. Year 2 benefits apply during the subscriber’s second 12 months of continues coverage. Year 3 benefits apply during the subscriber’s third 12 months of continues coverage.

Out-of-network dentists can bill you for charges above the amount covered by your Dominion Dental plan. To ensure you do not receive additional charges, visit a dentist in the Dominion Dental PPO network.

  Out of Network
  Year 1* Year 2* Year 3*
Preventive Dental Benefits:
Routine exams, teeth cleanings (2), bitewing X-rays.
Plan Pays
90% of in network fee schedule
Basic Dental Benefits
Fillings, X-rays, simple extractions.
Plan Pays
30% of in network fee schedule
Plan Pays
50% of in network fee schedule
Plan Pays
70% of in network fee schedule
Major Dental Benefits
Oral surgery (surgical extractions & impactions), endodontics, periodontics, crowns, bridges, dentures.
Plan Pays
10% of in network fee schedule
Plan Pays
20% of in network fee schedule
Plan Pays
40% of in network fee schedule
Dental Deductible
Per calendar year, per insured person for Preventive, Basic, & Major Services.
$50
Maximum Dental Benefits
Dental Benefits Per calendar year, per insured person.
$1,000
Access PPO Kids
 
  In Network
(Plan Pays)
Out of Network
(Plan Pays)
Preventive Dental Benefits:
Routine exams, teeth cleanings (2), bitewing X-rays.
100% Plan Pays 80% of in network fee schedule
Basic Dental Benefits
Fillings, simple extractions.
35% Plan Pays 20% of in network fee schedule
Major Dental Benefits
Endodontics, periodontics, oral surgery (surgical extractions & impactions), crowns, bridges, dentures.
25% Plan Pays 10% of in network fee schedule
Dental Deductible
Per child, per insured person for Basic & Major Services (and in-network Orthodontia).
$100
($200 for two or more children)
Medically Necessary Orthodontia
Per calendar year, per insured person for Preventive, Basic, & Major Services. (DC, DE, PA, VA)
Plan Pays 50% Plan Pays 0% of in network fee schedule
Medically Necessary Orthodontia
Per calendar year, per insured person for Preventive, Basic, & Major Services.(MD)
Plan Pays 50% Plan Pays 30% of in network fee schedule
Maximum Dental Benefits
Per calendar year, per insured person.

Per calendar year, per insured person.

In Network:
$350 out-of-pocket maximum per child (maximum of $700 for two or more children).

There is a 24-month waiting period for medically necessary orthodontic benefits.

Out of Network:
DC & MD: NA
PA, VA & DE: NA