Primecare Dental plan
A. Enrollment and Eligibility
The covered services of this plan are available to members as long as they live or work in the Plan’s service area. Provisions that apply to all members who are enrolled in the Plan:
- Dependents include newborn infants, whose coverage commences from the moment of birth.
- Adopted, foster, and step children whose coverage commences from the date of placement.
- Unmarried children under 19 years of age, who are mainly dependent on the member for support.
- Full time students under 23 years of age, which are unmarried and mainly dependent on the member for financial support. Submission of a student verification form, in regard to the student’s full time status is mandatory.
Coverage continues while a dependent child is incapable of self-sustaining employment by reason of physical handicap or mental retardation, and is chiefly dependent upon member for support and maintenance. The member is required to provide the Plan with proof of such dependency and incapacity within 31 days of the dependent attaining the limiting age standard, and every two years thereafter, as set forth by the Plan. The Plan should be advised, by the member, of changes in dependent status due to age.
B. Your Effective Date
If your application and payment information is submitted before the 25th of the month, your coverage will be effective on the 1st of the following month. If it is submitted after the 25th of the month, your coverage will be effective on the 1st of the second following month.
C. How does the Primecare Dental plan work?
With these dental plans you choose a Primecare Dental general dentist from the online directory. This is the dentist that will provide your basic dental care. If you enroll family members on the plan, they may choose their own dentist from the Primecare Dental list. Once you have been accepted on the plan and received your ID card, you can schedule an appointment with your Primecare general dentist. There are no waiting periods, no plan maximum and no deductible.
D. Annual Deductible & Calendar Year Maximums
There are no deductibles and no annual maximums.
E. Choice of Provider
When you enroll in the Primecare Dental, you and each enrolled family member choose a selected general dental office from the extensive Primecare Dental network. Each family member may select a different dental office.
F. Specialty Care/Specialty Referrals
Primecare dental covers all dental specialty treatments including implants, cosmetics, sedation, orthodontics, and much more.
G. Emergency Dental Services
If there is no Primecare provider within 30 road miles, you may seek emergency treatment at any dental office. Primecare will reimburse you up to $100 upon presentation of a receipt or statement showing the emergency treatment received by you or your family member.
H. Coordination of Benefits
Primecare Dental is available as primary coverage and does not coordinate coverage with other dental benefits, if you have them.
I. Cancellation Policy
You may cancel your policy at any time by notifying Member Services your request in writing. You will receive a refund of the premium only. The processing fee is non refundable.
J. Termination of Policy
Coverage terminates on the earliest of the following dates:
- The last day of the month your membership in the association terminates or immediately when this program ends.
- The last day of the month in which you cease to be eligible for coverage.
- The last day of the month in which youryou’re dependent is no longer a dependent, as defined.
- Subject to the grace period, the last day of the month for which a premium has been paid by you or on your behalf.
- Full mouth X-rays: Limited to one (1) set every three (3) years unless diagnostically necessary.
- Bitewing X-Rays: Two (2) sets in any twelve (12) month period unless diagnostically necessary.
- Sealants: Limited to molars, up to the 16th birthday.
- Fluoride: Up to the 18th birthday two(2) in any twelve (12) month period.
- Delivery of removable prosthodontics includes adjustments within six months of delivery date of service.
- Periodontal scaling and root planning: Limited to four (4) quadrants per twenty-four (24) consecutive months in combination with routine prophylaxis.
- The copayments listed for endodontic procedures do not include the cost of the final restoration.
- Panoramic x-rays: One (1) in any three (3) year period unless diagnostically necessary.
- Prophylaxis: covered once every six consecutive months.
- Reline of a complete or partial denture: One (1) per denture in any twelve (12) month period, unless dentally necessary.
- Rebase of a complete or partial denture: One (1) per denture in any twelve (12) month period, unless diagnostically necessary.
- 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.
- 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.
- Treatment of malignancies, cysts, or neoplasm.
- Periodontal grafting or splinting.
- 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.
- General anesthesia, analgesia, intravenous /intramuscular sedation or the services of an anesthesiologist.
- Elective or cosmetic dentistry that are cosmetic in nature including, but not limited to bonding, bleaching teeth or dentures, posterior composites, porcelain veneers unless covered as a benefit.
- Orthodontic treatment in process, or extractions for orthodontic purposes.
- 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.
- Precision attachments, stress breakers, magnetic retention or overdenture attachments.
- Cephalometric x-rays, except when performed as part of the orthodontic treatment plan and records for a covered course of comprehensive orthodontic treatment.
- Inlays, onlays, crowns or fixed bridges started, but not completed, prior to the Member’s eligibility to receive benefits under this Plan.
- (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).
- Dentures or orthodontic treatment started prior to the Member’s eligibility to receive benefits under this Plan.
- (Dentures are considered to be started when the impressions area taken. Orthodontic treatment is considered to be started when the teeth are banded).
- Replacement of lost or stolen prosthetics or appliances including crowns, bridges, partial dentures, full dentures, and orthodontic appliance.
- 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.
- Any procedure or treatment unable to be performed in the dental office due to the general health or physical limitation of the member.
- Dental implants and services associated with the placement of implants, prosthodontic restoration of dental implants, and specialized implant maintenance services.
- 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.
- Dispensing of drugs supplied in a dental office.
- 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.
- 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.
- Root canal treatment started, but not completed, prior to the Member’s legibility to receive benefits under this Plan. (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.)
- 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.
- 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.
Primecare Dental 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.
- Re-treatment of orthodontic cases, or changes in orthodontic treatment necessitated by any kind of accident.
- Replacement or repair of orthodontic appliances damaged due to the neglect of the Member.
- Tracings, records, study models, x-rays and photographs.
- Initial examination, consultation, diagnosis, treatment planning, retention appliances and related visits.
- Cephalometric x-rays.
- Lost or broken appliances.
- Myofunctional therapy.
- Surgical procedures such as extractions of teeth strictly for the purpose of orthodontia.
- Any jaw surgical procedure related to orthodontia.
- Dental services of any nature, performed in hospital or convalescent home or anywhere outside the office or Plan provider.
- Dispensing of drugs not normally supplied in an orthodontic practice.
- Treatment related to Temporomandibular Join Dysfunction or hormonal imbalances.
L. Grievance Procedures
Please call member services for all provider and service inquiries.
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, exceptions and limitations is contained in the Certificate of Coverage.