Select Plan Basic
Select Plan Basic benefits include:
- No waiting periods and plan maximums
- No charge for oral exams
- $13 charge for routine semiannual cleanings (additional cleaning is covered for expecting mothers and diabetics)
- No charge for bitewing X-rays
- Discount on all implant services
These procedures account for over 65% of dental services for most frequently performed for adults, and over 90% of the most frequently performed services for children (Based on Dominion’s annual review of utilization data).
See Fee Schedule for Select Plan Basic 703xa benefits here
Select Plan Basic Kids benefits include:
- No charge for exams, cleanings, bitewing X-rays and other preventive services
- Discount on non-medically necessary orthodontia.
See Fee Schedule for Select Plan Basic Kids (under age 19) benefits here
|White Filling:||From $69|
|Root Canals:||From $341|
|Fee Schedule | Dentist Search||Exams:|
|No charge for Periodic oral examination twice per calendar year per person|
Office visit copay – $10
|$13 for Adult Prophylaxis (cleaning) twice per calendar year per person||X-Rays:|
|No charge for bitewing x-rays – 1 to 4 films, twice per calendar year per person|
$30 for panoramic film once in three (3) years per person
|$41 for Amalgam filling-one surface, primary or permanent|
$69 for (white filling) Resin based composite-one surface, anterior
$73 for Resin based composite-one surface, posterior
|$69 for (Simple) Extraction, erupted tooth or exposed root||Crowns:|
|$523 for crown-porcelain fused metal|
$560 for crown – porcelain/ceramic substrate
See complete fee schedule for different types of crowns covered
|$341 for endodontic (root canal) therapy-anterior|
$512 for endodontic (root canal) therapy-molar
|$697 for complete denture (maxillary)|
$697 for complete denture (mandibular)
|$74 for Periodontal maintenance||Implants:|
|All Implant Services – 15% Discount||Braces/Orthodontia:|
|$3,658 for comprehensive orthodontic treatment – adult dentition.|
$3,422 for comprehensive orthodontic treatment – adolescent dentition.
|Not covered service||Additional Network Information:|
You may choose any of the conveniently located dental offices from the list of participating dentists. Each family member may select a different participating dentist. Specialty care is covered on this plan. The fees apply only when services are performed by your selected general dentist. Plan Specialist, if available, will reduce fees 25% from Usual, Customary, and Reasonable (UCR) fees, except in the State of Delaware. In Delaware, Plan Specialists will provide a reduction from their UCR that will vary between specialists.Exclusions and Limitations
Plan Brochure: N/A
Can I change my dentist once I am in the plan?
You may change your selected dentist any time by contacting Member Service Department. If notification is received by Dominion National by the 20th of the month the change will be effective on the first of the following month. All outstanding bills with the current dental office MUST be paid before the change will be made effective.
What is a pre-existing condition versus work-in-progress? Is it covered?
A pre-existing condition is an oral health condition, which existed before your enrollment in a dental program. The plan does not include an exclusion for pre-existing conditions.
Work in progress refers to dental treatment that is in the process of being completed. Under certain specific circumstances, work in progress is covered under your plan. Under most circumstances, work in progress is not covered.
What provider options do I have?
You may choose any of the conveniently located dental offices from the list of participating dentists. Each family member may select a different participating dentist.
When can I start using my Plan?
You can start using your plan once it goes into effect - usually the 1st of the month following your enrollment (as long as the enrollment and payment is received within the enrollment deadline). Incomplete enrollment forms or failure to submit the required initial premium amount may cause an initial delay in issuance of insurance. Do not cancel any other insurance or assume you are insured under the Plan until you receive your certificate of insurance.
When will I receive my new member kit and what will it include?
An enrollment package will be mailed to you before your first day of eligibility. It will include an ID card, a Description of Benefits & Member Copayments and Certificate of Coverage, which detail your new dental plan.
Who can enroll in this plan?
You and your dependents are eligible. Dependents include your spouse and unmarried children up to age 26.
As long as you meet the plan’s general eligibility requirements and pay the applicable premium, your acceptance is automatic.
Arlington, VA 22202
Disclaimers and Disclosures:
This website provides a very brief description of some of the important features of this plan. It is not the insurance contract, nor does it represent the insurance contract. A full description of benefits, exclusions and limitations is contained in the Schedule of Benefits and your policy.
Rates shown are based upon the information you provided, and are subject to change based on the dental and/or vision plan's underwriting practices and your selection of available optional benefits, if any. Final rates and effective dates are subject to underwriting and are always determined by the dental insurance and/or vision insurance company. To be considered for reimbursement, expenses must qualify as covered expenses.
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