Plan Information

Dental Plus Basic

Solstice Dental Plus Basic Plan Information

A. Enrollment and Eligibility

Coverage is offered to individuals who are 18 years of age and older, and their eligible dependants. Your lawful spouse or domestic partner (with 6+ months history) or your unmarried child (including newborns, adopted children - from moment of birth if agreement is entered into, stepchildren, a child for whom you must provide dental coverage under a court order; or a Dependent child who resides in your home as a result of court order or administrative placement) who is:

  1. Less than 19 years old.
  2. Less than 25 years old if he or she is both:
    - Reliant upon you for maintenance and support.
  3. Any age if he or she is both:
    - Incapable of self-sustaining employment due to mental or physical disability.
    - Reliant upon you for maintenance and support.

B. Your Effective Date

Plan effective dates are always the 1st of the month. If the enrollment form and payment information are received by the 5th of the month, coverage will become effective on the 1st of the same month. Otherwise, the coverage will not start until the 1st day of next month. Incomplete enrollment forms or failure to submit the required initial fee amount may cause an initial delay in issuance of membership. Do not cancel any other membership or assume you are enrolled under the Plan until you receive your ID card.

C. How does the Dental Plus plan work?

Simply select a participating provider near you from the directory and show your card at the time of service. You must pay the provider at the time of service to receive your discount.

D. Choice of Provider

You must seek services by a participating open access network dentist to receive discounted dental services. No need to select a primary dentist or be assigned to an office roster!

E. Specialty Services

  1. This Member Fee Schedule applies when listed dental services are performed by a participating General Dentist, unless otherwise authorized by Solstice.
  2. Procedures not listed on the Member Fee Schedule that are performed by a participating General Dentist will be charged at the participating General Dentist’s usual and customary fee less 25%.
  3. The participating General Dentist you select may not perform all procedures listed. The fees shown apply to participating General Dentists who do perform these services. Therefore, you are encouraged to secure availability of the scheduled services with your participating General Dentist.
  4. Should the services of a specialist (Oral Surgeon, Endodontist, Orthodontist, Periodontist, or Pediatric Dentist) be necessary, you may go directly to a participating specialist and receive a 25% reduction off the provider’s usual and customary fee.

F. Emergency Dental Services

In case of an emergency, a Member should contact their usual network Provider. If he/she is unavailable, contact Solstice Member Services who will assist in locating another Provider.

G. Cancellation Policy

If you cancel your membership with the discount medical plan organization within 30 days of the effective date of enrollment on the plan, you shall receive a reimbursement of all periodic charges upon the return of the discount card to the discount medical plan organization. The one-time processing fee is $30. Please note: The processing fee is non-refundable.

H. Exclusions

  1. Services performed by a dentist or dental specialist, not contracted with Solstice
  2. Any dental services or appliances which are determined to be not reasonable and/or necessary for maintaining or improving the Member’s dental health or experimental in nature, as determined by the participating Solstice dentist.
  3. Orthographic surgery or procedures and appliances for the treatment of myofunctional, myoskeletal or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Member Fee Schedule.
  4. Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions, or medications.
  5. Treatment of malignancies, cysts, or neoplasms, without proof of medical necessity and prior Solstice approval.
  6. Dental procedures initiated prior to the Member’s eligibility under this benefit plan or started after the Member’s termination from the plan.
  7. Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the Member, including but not limited to, physical or emotional resistance, inability to visit the dental office, or allergy to commonly utilized local anesthetics.
  8. D9972 Excludes bleaching material for home use.

I. Limitations

  1. Any oral evaluation is limited to one (1) time in any six (6) consecutive month period at no charge. All subsequent oral evaluations will be at a 25% discount off the doctor’s usual and customary fee without a frequency limitation.
  2. Bitewing X-rays (2–4 films) are limited to one set in any twelve (12) consecutive month period.
  3. The dental prophylaxis or periodontal maintenance procedure is limited to one in any six (6) consecutive month period. Any additional procedures will follow D1110 and D4910 member fee as listed in the Member Fee Schedule.
  4. Fluoride treatment is limited to one (1) in any twelve (12) consecutive month period for children under the age of 16.
  5. Sealants are limited to one (1) time per tooth in any three (3) consecutive year period. This is only allowed for unrestored permanent molar teeth for children under the age of 16.
  6. Space maintainers and all adjustments are limited to children under the age of 16.
  7. Harmful habit appliances are limited to one (1) time per person under the age of 16.
  8. Services performed by a dentist or dental specialist, not contracted with Solstice without prior approval.
  9. Any dental services or appliances which are determined to be not reasonable and/or necessary for maintaining or improving the member’s dental health or experimental in nature, as determined by the participating Solstice dentist.
  10. Orthographic surgery or procedures and appliances for the treatment of myofunctional, myoskeletal or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Member Fee Schedule.
  11. General anesthesia or IV sedation unless otherwise listed as a covered benefit on the Member Fee Schedule.
  12. Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions, or medications.
  13. Treatment of malignancies, cysts, or neoplasms.
  14. Dental implants and related services.
  15. Dental procedures initiated prior to the member’s eligibility under this benefit plan or started after the member’s termination from the plan.
  16. Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the member including but not limited to physical or emotional resistance, inability to visit the dental office, or allergy to commonly utilized local anesthetics.
  17. New dentures include one (1) reline within the first six (6) months.
  18. Replacement of crowns, fixed bridges or dentures is limited to once every five (5) years.
  19. When crown and/or bridgework exceed six (6) consecutive units, there will be an additional charge of $30.00 per unit.
  20. Member fees for endodontic procedures do not include the cost of the final restoration.
  21. D9972 Excludes bleaching material for home use.
  22. Lab and related costs are included in the listed member fee.
  23. Copies of X-rays can be obtained for $2 per periapical film up to a maximum of $30. Panoramic X-rays can be obtained for a $15 fee.

J. Grievance Procedures

Please call Member Services for all provider and service inquiries.

K. Disclaimer

This plan does not include all procedures, which might be provided by a general dentist. Any procedure delivered which is not listed on the fee schedule may cause additional cost to be incurred. These additional costs are the responsibility of the Member. The dollar amount specified adjacent to each procedure may not be the only cost incurred for a given treatment, because the treatment may require more than one dental procedure.