Individual Dental Copay Plans
Adding a LifeWise dental plan to your health plan means you’ll have complete high-quality coverage. Since research indicates that good oral health is key to your overall health, there’s really no reason not to enroll. Especially when you consider our new dental plans offer predictable costs on over 200 dental procedures. With a strong and growing provider network, you’re sure to find a preferred dentist conveniently located near you.*
LifeWise Dental plans feature:
- Choice of deductible - choose either a $50 or $75 annual deductible plan.
- Predictability of costs - you’ll pay one set copay for each of the over 200 covered services
- Easy plan administration - one application, one bill, one ID card, one customer service line and one resource rich website.
- Wide range of coverage - you’ll be covered for the most commonly used preventive, minor and major dental services.
- Choice of providers - use our “find a doctor” tool to find a dentist in your area. Choose “Dental-Individual Copay Plans” from the Network drop-down list.
|Annual Deductible PCY|| Individual: $50 / $75
Family: $150 / $225
|Benefit Maximum per person, PCY||$1,000|
|Commonly Used Covered Services||Preferred||Non-Preferred|
|DIAGNOSTIC AND PREVENTIVE (no deductible applies)||$50 or $75 deductible plan||$50 deductible plan||$75 deductible plan|
|Oral Exams limited to 2 PCY||$0||20%||30%|
|Cleanings limited to 2 PCY||$20|
| Fluoride Treatments limited to 2 applications PCY for members
under the age of 20
|Sealants limited to permanent teeth; for members under age 19||$0|
|BASIC (deductible applies first)||$50 or $75 deductible plan||$50 deductible plan||$75 deductible plan|
|Emergency Palliative Treatment||$5||40%||50%|
|Fillings one surface, amalgam; primary or permanent; limited to once per tooth surface every 24 consecutive months||$30|
|Periodontal Maintenance limited to 4 visits per calendar year||$40|
|Recementing of Crowns||$20|
|Simple Extractions erupted tooth or exposed root||$30|
|Space Maintainers fixed, unilateral; for members under age 20||$65|
|MAJOR (12 month waiting period; deductible applies first)||$50 or $75 deductible plan||$50 deductible plan||$75 deductible plan|
|Crowns, Onlays, Dentures, Partials and Bridges||
Copays vary based on the tooth location and type of material used.
|Endodontic (Root Canal) Treatment limited to 2 per arch when
performed in conjunction with overdentures
|anterior tooth: $385
molar tooth: $515
bicuspid tooth: $435
|General Anesthesia for first 30 minutes; limited to covered dental procedures at a dental-care provider's office when dentally necessary||$165|
|Oral Surgery for surgical removal of residual tooth roots||$115|
|Periodontal Scaling one to three teeth; limited to 2 every 12
|Periodontal Surgery osseous surgery; one to three contiguous
teeth; limited to 2 every 12 consecutive months
|* If you visit a non-preferred provider, you'll pay the applicable non-preferred coinsurance based on the type of service provided. You'll also be responsible for amounts charged in excess of the allowable charge.|
|Age Band||$50 Deductible||$75 Deductible|