PrimeStar Personal Dental Plan Guidelines and Exclusions
Eligible Expenses
We will pay for Eligible Expenses You incur for Yourself or on behalf of Your insured Dependent. Expenses must be incurred while the Policy is in force and the person is covered by the Policy. The description of Eligible Expenses is shown in the Coverage Schedule. To be an Eligible Expense, the dental service or procedure must be performed by a Dentist, a Physician or a Dental Hygienist.
Expenses Incurred
An Eligible Expense is considered incurred on the following dates: For full and partial dentures - the date the final impression is taken; for fixed bridges, crowns, inlays and onlays - the date the teeth are first prepared; for root canal therapy - on the date the pulp chamber is opened; for periodontal surgery - on the date surgery is performed; for all other services - the date the service is performed.
Deductible Amount
The calendar year Deductible, if any, is shown in the Coverage Schedule. The Deductible is an amount of charges You must incur for Yourself or on behalf of Your insured Dependent before We start paying benefits.
Calendar Year Maximum
The maximum limit payable for all Eligible Expenses in any calendar year is shown in the Coverage Schedule. The Calendar Year
Maximum, if any, will apply to each person covered under the Policy.
Pretreatment Review
If the Course of Treatment will exceed the amount shown in the Coverage Schedule, We will request prior review. We must be given the Dentist's treatment plan consisting of a description of the planned treatment with estimated charges and diagnostic x-rays. We will determine Eligible Expenses and state how much We will pay for the treatment. Our determination may suggest an alternate less expensive Course of Treatment if it will produce professionally satisfactory results. If You do not request a pretreatment review We will pay for the least expensive method of treatment regardless of the method actually used.
Coordination of Benefits (Does not apply in Maryland or South Dakota)
If any person under the Policy (referred to as "this Plan") is also covered under one or more other plans, the benefit under this Plan will be coordinated with benefits payable under all other plans.
Alternate Benefit
If: 1) We determine that a less expensive alternate procedure, service or Course of Treatment can be performed in place of the proposed treatment to correct a dental condition; and 2) the alternative treatment will produce a professionally satisfactory result; then the maximum We will allow will be the charge for the less expensive treatment.
Missing Tooth
When covered under your plan, benefits are provided for placement of dentures,
fixed bridgework, implants or the addition of teeth to existing dentures only when
the service includes replacement of a natural tooth extracted or lost while covered
under this plan. This limitation ends after the individual receiving care has been
covered under this plan for 36 consecutive months.
Eligibility
Individuals, 18 years of age or older, plus their eligible dependents (spouse and unmarried children from birth to age 19; extended to age 23 if child is a full-time student). This is subject to State requirements.
Termination of Coverage
Coverage terminates on the earliest of the following dates: (a) the last day of the month in which You cease to be eligible for coverage; (b) the last day of the month in which Your Dependent is no longer a dependent as defined; (c) subject to the Grace Period, the last day of the month for which a premium has been paid by you or on your behalf; (d) or the date the Master Policy ends.
Effective Date
You and Your Dependents are covered on the later of: the date We accept Your enrollment and determine an effective date; or the date You first acquire a Dependent, if the date is after Your coverage begins.
Reasonable and Customary
Reasonable and Customary means the usual, customary and regular charges for the area where such expenses are incurred.
Dental Expenses NOT Covered
- for overdentures and associated procedures
- for charges in excess of those considered reasonable and customary;
- for cosmetic procedures;
- for the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function;
- for implants and for replacement of lost or stolen appliances, replacement of retainers, athletic mouthguards, precision or semi-precision attachments, denture duplication;
- for oral hygiene instructions and for plaque control, completion of a claim form, acid etch, broken appointments, prescription or take-home fluoride, or diagnostic photographs;
- for services not completed by the end of the month in which coverage ends unless continuation of coverage has been requested and accepted by Us;
- for procedures that are begun, but not completed;
- for services and treatment provided without charge or for which there would be no charge in the absence of insurance;
- for services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries;
- for a condition covered under any Worker's Compensation Act or similar law; that are applied toward satisfaction of a Deductible, if any; that are generally considered by the dental profession as experimental or investigational;
- for the treatment of cleft palate and anodontia;
- for services or supplies payable under any medical expense plan;
- for orthodontia, unless included within Coverage Schedule;
- for services rendered prior to the date the Insured is covered under the Policy;
- for the diagnosis or treatment of Temporomandibular Joint Dysfunction (TMJD);
- for hospital services;
- for any unmarried child age 19 years of age and over unless he is dependent upon You for support, while a full-time student. A full-time student is one who is enrolled for 12 semester hours for credit in an accredited junior college, college or university. Any exception for a full-time student will end at age 23;
- during any waiting period We require, when You voluntarily end Your insurance and re-enroll at a later date, Your waiting period is 2 years and begins on the date Your coverage first ended.
Vision Expenses NOT Covered
- The cost of a lens in excess of a standard lens will not be covered. A standard lens is any lens which fits a frame with an eye size less than 61mm. Charges for replacement lenses will not be covered unless there is a change in prescription.
- The cost of a frame in excess of a standard frame will not be covered. A standard frame is any frame which has a retail value of $75.00 or less. The cost of replacement frames will not be covered, unless the existing frame is not compatible with the replacement lenses.
- In addition to the above, the following expenses are not covered:
- any procedure, service or supply included as a covered medical expense under any group insurance plan, whether benefits are payable as to all or only part of such charges;
- special procedures, such as orthoptics, vision training and subnormal vision aids;
- plano or prescription sunglasses or other special purpose vision aids;
- medical or surgical treatment of the eyes, including hospital expenses;
- replacement of lost or broken lenses and/or frames;
- duplicate glasses or lenses or frames; and
- services or material not listed as an Eligible Expense.
PrimeStar Personal Dental Plans provide for an increased coinsurance level based upon each Benefit Year of coverage. Benefit Year begins with each insured's effective date and continues for 12 months. Each primary insured and dependent will have their own benefit year beginning with their specific effective date of coverage.
PrimeStar Personal Dental Plans will reimburse you for covered dental expenses based upon the Reasonable and Customary (R&C) fees for those covered expenses.
PrimeStar Plan Guidelines and Exclusions
Terminology
Frequently Asked Questions