Access PPO 1
Plan Information

Plan Information (Adult Plans)

A. Enrollment and Eligibility

You and your dependents are eligible. Dependents include your spouse and unmarried children up to age 26.

B. Your Effective Date

If your application and payment are received by the 25th of the month, your program will be effective on the first day of the following month.

C. How do I receive care?

After your effective date, simply call your dental office, make an appointment and present your membership card upon arrival. There are no waiting periods. You simply pay any fees to your dental office at the time of service.

D. Annual Deductible & Calendar Year Maximums

There is a calendar year deductible of $50 per insured person applicable to all services (waived on preventive care services for Access PPO 3).

There is a maximum benefit of $1,000 per calendar year, per insured person for the Access PPO 1 and Access PPO 3. There is a $750 per calendar year maximum benefit per insured person for the Access PPO 2 plan.

E. Choice of Provider

You may choose any of the conveniently located dental offices from the list of participating dentists, or you may receive care from any licensed dentist. Use a participating Access PPO network dentist for greater coverage.

F. Specialty Care/Specialist Referrals

Access PPO plan subscribers may receive services from any licensed dentist, including specialists, without a referral from a general dentist.

G. Emergency Dental Services

Access PPO Plan subscribers may receive emergency dental services from any licensed dentist and file a claim in the normal fashion.

H. Coordination of Benefits

This program may be coordinated with additional dental coverage you may have. This coverage can only be coordinated as the primary program.

I. Termination or Cancellation

Benefits shall cease upon the earliest of the following events:

  1. On the date of expiration of the period for which the last payment of Monthly Membership Fees was made to Program. In the event that subscriber wishes to continue coverage for an additional year, a grace period of 31 days from the due date shall be granted for payment.
  2. Upon date of dependents attaining the age of 26 years, benefits to such dependents shall cease.
  3. If after reasonable efforts to establish and maintain a satisfactory dentist-patient relationship, the Participating Dentist is unable to do so, the Program reserves the right to transfer the Subscriber and Dependents to a second and third Participating Dentist of their choice. If the third Participating Dentist is also unable to establish a satisfactory dentist-patient relationship, the Program reserves the right to terminate the membership of said Subscriber and Dependents.
  4. Upon violation of the terms of the contract, fraud or deception in the use of services, under which the Member is covered.

J. Access PPO plan expenses not covered:

No benefits will be paid for expenses incurred:

  1. Treatment required for conditions resulting while on active duty as a member of the armed forces of any nation or from war or acts of war, whether declared or undeclared.
  2. Services which are covered under Medicare, worker’s compensation, employer’s liability laws, or the Pennsylvania Motor Vehicle Financial Responsibility Law.
  3. Services and treatment provided without charge or for which there would be no charge in the absence of insurance.
  4. Services not listed as covered.
  5. Hospitalization for any dental procedure.
  6. Services and treatment for which Member is eligible for coverage under his or her hospital, medical/surgical or major medical plan.
  7. Reconstructive, plastic, cosmetic, elective or aesthetic dentistry.
  8. Elective surgery including, but not limited to, extraction of nonpathologic, asymptomatic impacted teeth.
  9. Replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function.
  10. Replacement of lost, stolen or damaged prosthetic or orthodontic appliances; athletic mouthguards; precision or semi-precision attachments; denture duplication; sealants; periodontal splinting of teeth.
  11. Services for increasing vertical dimension, restoring occlusion, replacing tooth structure lost by attrition, and correcting developmental malformations and/or congenital conditions.
  12. Oral hygiene instructions; plaque control; completion of a claim form; acid etch; broken appointments; prescription or take-home fluoride; or diagnostic photographs.
  13. Dispensing of drugs.
  14. Diagnosis or treatment of temporomandibular joint (TMJ) syndromes, problems and/or occlusal disharmony.
  15. Procedures that in the opinion of Dominion National are experimental or investigative in nature because they do not meet professionally recognized standards of dental practice and/or have not been shown to be consistently effective for the diagnosis or treatment of the Member’s condition.
  16. Treatment of cleft palate, anodontia, malignancies or neoplasms.
  17. Any service or supply rendered to replace a tooth lost prior to the effective date of coverage. This exclusion expires after 36 months of Member’s continuous coverage under the plan.
  18. Maryland policyholders only: Any bill, or demand for payment, for a dental service that the appropriate regulatory board determines was provided as a result of a prohibited referral. “Prohibited referral” means a referral prohibited by Section 1- 302 of the Maryland Health Occupations Article.

K. Grievance Procedures

Complaints should be initially brought to the attention of the Member’s Participating Dentist. If the issue is not resolved to the Member’s satisfaction, it may be sent in writing to the Director of Member Services, Dominion National, 115 South Union Street, Suite 300, Alexandria, Virginia 22314.

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