Page 4 - Golden Dental Plans – HealthChoice Welcome Dental Program

Welcome Dental Program Schedule of Benefits
OFFICE VISIT FEE..............................................................................................................................$5.00
CLASS I Preventive and Diagnostic*
Exams...................................................................................................................................................100% Xrays (Periapical and/or Bitewing) ..................................................................................................................100% Prophylaxis ...........................................................................................................................................100% Fluoride (child) ........................................................................................................................................100% CLASS II Basic Restorative
Performed by General Dentist
Fillings ....................................................................................................................................................75% Root Canals............................................................................................................................................75% X-rays - (FMX** or Panaormic)........................................................................................................................75% Extractions - Simple/Surgical.................................................................................................................75%
CLASS III Prosthetic***
Crowns ...................................................................................................................................................50% Bridges ...................................................................................................................................................50% Partial or Complete Dentures .................................................................................................................50%
CLASS IV Specialty Care
Endodontics ...........................................................................................................................................50% Periodontics ...........................................................................................................................................50% Oral Surgery ...........................................................................................................................................50% Pedodontics (up to age 7) ...........................................................................................................................50%
CLASS V Orthodontics****
Child (up to age 19) ...................................................................................................................................$1,500.00
Adult (member and spouse) ............................................................................................................................$750.00
Annual Maximum..........................................................................................................$1,500.00 (Per family member, General Dentistry only)
Specialty Maximum .........................................................................................................$500.00 (Per family members, 6 month waiting period.)
Emergency Out-of-Area Palliative Treatment - $100.00 benefit
*Once every 6 months at a general dentist
**Full mouth series of x-rays are covered once every 36 months.
***Crowns and Dentures are covered once every 5 years. Porcelain on crowns posterior to the 1st and 2nd premolars are considered cosmetic dentistry and therefore are not a covered benefit. Patient may incur additional out-of-pocket charges for lab work and/or upgraded materials for fillings, crowns, bridges, partial or complete dentures, space maintainers, appliances and any repairs to stated items.
****Member must have twelve (12) months of continuous coverage for Orthodontic Benefit.
All specialty appointments must accompany primary care referral.
See member handbook for complete plan limits and exclusions.
1. Fillouttheapplication.
How it works.
2. Selectadentalofficefromtheproviderdirectory-or-visitwww.goldendentalplans.com.Fromthehomepagegoto'Finda Dentist Near You', enter your zip code and click SUBMIT. this will provide a list a providers in your area. Be sure to include the office facility number on your application.
3. Selectyourmethodofpayment,check,moneyorderorcreditcard.MakecheckspayabletoHealthChoiceWelcomeDental Program.
4. Returnthecompletedapplicationandpayment.Usetheenclosedreturnenvelopeandmailto: HealthChoice of Michigan Welcome Dental Program
500 Griswold Street – 15th Floor, South Detroit, MI 48226
5. Applicationsreceivedbythe15thofthemonthwillbeeligibleforcoverageeffectivethefirstdayofthefollowingmonth.
6. YourGoldenDentalPlansofMichiganWelcomePacketwillbemailedoutwithin2weeksafterwereceiveyourapplication.
7. IfyouhaveanyquestionabouttheWelcomeDentalProgram,pleasecontactGoldenDentalPlansofMichiganat1-800- 451-5918 or visit our website at www.goldendentalplans.com and click on HealthChoice Logo to find a provider in your area. To contact HealthChoice of Michigan, please call 1-800-WELL-NOW.