Page 5 - Golden Dental Plans – HealthChoice Small Business Dental Program

Small Business Plan
ANNUAL MAXIMUM
General Dentistry: UNLIMITED
COSMETICS
• Zoom Bleaching - $299.00 ($700.00 value) contact GDP for participating providers • Veneers and Implants – a 25% discount contact GDP for participating providers
SPECIALTY CARE
SPECIALTY CARE
ANNUAL MAXIMUM for Specialty Care: $1,000.00
WAITING PERIOD: 6 Months from enrollment
COVERAGE LEVEL: 35%
• Member must be enrolled for six consecutive months
• Member must obtain referral from Primary Dentist.
• Member must utilize an In-Network Specialist (Contact GDP for list of providers).
• Member is responsible for 65% of the Specialist’s fee for listed procedures, including evaluations and x-rays.
• Pedodontics is covered at 65% for dependents up to age 7 without a referral.
*Once every 6 months at a general dentist. Adult cleanings are covered 3 per contract year; 3rd adult cleaning is covered at 50%. **Procedure must be performed by a general dentist
***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 list of limitations and exclusions