The member receives Most diagnostic preventive care at NO cha rge Cosmetic treatment The following member payments apply when a participating General Dentist performs services Par ticipating Specialists are available at fees discounted off of the ID: 18940
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SOL221PP10108SolsticeBenefits,Inc.isalicensedPrepaidLimitedHealthServicesOrganization,DiscountMedicalPlanOrganizationunderChapter636F.S.andThirdPartyAdministratorunderChapter626F.S. PlusPlanOnePlusPlanOneHighlightsMembersofthePlusPlanOnedentalplanareeligibletoreceivebenefitsimmediatelyupontheeffectivedateofcoveragewith:•Twofreecleanings(onceevery6months)•Discountsongeneralandspecialtyprocedures•TopicalapplicationforchildrenatnochargeThememberpaymentslistedareguaranteedtobebetween30%and40%discountandareofferedbyaparticipatingSolsticeprovider.Thememberreceives:•Mostdiagnostic&preventivecareatNOcharge•CosmetictreatmentThefollowingmemberpaymentsapplywhenaparticipatingGeneralDentistperformsservices.ParticipatingSpecialistsareavailableatfeesdiscountedoffoftheirusualandcustomarycharges.An“*”denoteslimitationoncertainbenefits(see“Exclusion/Limitations”)Thisplanisnotdentalinsurance.Thisplanprovidesdiscountsatcertaindentalprovidersfordentalservices.Theplandoesnotmakepaymentsdirectlytothedentalprovidersfordentalservices.Theplanmemberisobligatedtopayforalldentalcareservices,butwillreceiveadiscountfromthoseproviderswhohavecontractedwithSolsticeBenefits.SolsticeBenefits,Inc.,P.O.Box19199,Plantation,FL33318ExclusionsandLimitations1.Anyoralevaluationislimitedtoone(1)timeinanysix(6)consecutivemonthperiodatnocharge.Allsubsequentoralevaluationswillbeata25%discountoffthedoctor’susualandcustomaryfeewithoutafrequencylimitation.2.Bitewingrays(24films)arelimitedtoonesetinanytwelve(12)consecutivemonthperiod.3.Thedentalprophylaxisorperiodontalmaintenanceprocedureislimitedtooneinanysix(6)consecutivemonthperiod.AnydditionalprocedureswillfollowD1110andD4910memberfeeaslistedintheMemberFeeSchedule.4.Fluoridetreatmentislimitedtoone(1)inanytwelve(12)consecutivemonthperiodforchildrenundertheageof16.5.Sealantsarelimitedtoone(1)timepertoothinanythree(3)consecutiveyearperiod.Thisisonallowedforunrestoredpermanentmolarteethforchildrenundertheageof16.6.Spacemaintainersandalladjustmentsarelimitedtochildrenundertheageof16.7.Harmfulhabitappliancesarelimitedtoone(1)timeperpersonundertheageof16.8.Servicesperformedbyadentistordentalspecialist,notcontractedwithSolsticewithoutpriorapproval.9.Anydentalservicesorapplianceswhicharedeterminedtobenotreasonableand/ornecessaryformaintainingorimprovingthemember’sdentalhealthorexperimentalinnature,asdeterminedbytheparticipatingSolsticedentist.10.Orthographicsurgeryorproceduresandappliancesforthetreatmentofmyofunctional,myoskeletalortemporomandibularjointdisordersunlessotherwisespecifiedasanorthodonticbenefitontheMemberFeeSchedule11.GeneralanesthesiaorIVsedationunlessotherwiselistedasacoveredbenefitontheMemberFeeSchedule12.Anyinpatient/outpatienthospitalchargesofanykindincludingdentistand/orphysiciancharges,prescriptions,ormedications.13.Treatmentofmalignancies,cysts,orneoplasms.14.Dentalimplantsandrelatedservices.15.Dentalproceduresinitiatedpriortothemember’seligibilityunderthisbenefitplanorstartedafterthemember’sterminationfromtheplan.16.Anydentalprocedureortreatmentunabletobeperformedinthedentalofficeduetothegeneralhealthorphysicallimitationsofthememberincludingbutnotlimitedtophysicaloremotionalresistance,inabilitytovisitthedentaloffice,orallergytocommonlyutilizedlocalanesthetics.17.Newdenturesincludeone(1)relinewithinthefirstsix(6)months.18.Replacementofcrowns,fixedbridgesordenturesislimitedtoonceeveryfive5)years.19.Whencrownand/orbridgeworkexceedsix(6)consecutiveunits,therewillbeanadditionalchargeof$30.00perunit.20.Memberfeesforendodonticproceduresdonotincludethecostofthefinalrestoration.21.D9972Excludesbleachingmaterialforhomeuse.22.Labandrelatedcostsareincludedinthelistedmemberfee.23.CopiesofXrayscanbeobtainedfor$2perperiopticalfilmuptoamaximumof$30.PanoramicXrayscanbeobtainedfora$15fee.SpecialtyServicesThisMemberFeeScheduleapplieswhenlisteddentalservicesareperformedbyaparticipatinggeneraldentist,unlessotherwiseauthorizedbySolsticeBenefits.ProceduresnotlistedontheMemberFeeSchedulethatareperformedbyaparticipatinggeneraldentistwillbechargedattheparticipatinggeneraldentist’susualandcustomaryfeeless25%.Theparticipatinggeneraldentistyouselectmaynotperformallprocedureslisted.Thefeesshownapplytoparticipatinggeneraldentistswhodoperformtheseservices.Therefore,youareencouragedtosecureavailabilityofthescheduledserviceswithyourparticipatinggeneraldentist.Shouldtheservicesofaspecialist(OralSurgeon,Endodontist,Orthodontist,Periodontist,ProsthodontistorPeiatricDentist)benecessary,youmaygodirectlytoaparticipatingspecialistwithnoreferralandreceivea25%reductionofftheprovider’susualandcustomaryfee.Thepatient/memberisultimatelyresponsibleforverificationstotheaccuracyandappropriatenessofallfeesapplicabletoanySolsticedentalbenefitprovidedbyaSolsticenetworkprovider.Solsticeurgesallofitsmemberstoverifyallfeesforproposedtreatmentviathe“MemberFeeSchedule”and/orwithSolsticeMemberServicesDepartmentpriortotreatment. P.O.Box19199Plantation,FL33318Phone:8777602247Fax:9544768816www.SolsticeBenefits.com SOL221PP10108SolsticeBenefits,Inc.isalicensedPrepaidLimitedHealthServicesOrganization,DiscountMedicalPlanOrganizationunderChapter636F.S.andThirdPartyAdministratorunderChapter626F.S.PlusPlanOne APPOINTMENTS D0120Periodicoralevaluation$0D0140Limitedoralevaluationproblemfocused$10D0150Comprehensiveoralevaluationneworestablished$0PatientD0160Detailed/xtensiveoralevaluationproblemfocused$0D0170Reevaluationlimitedorproblemfocused$0D0180Comprehensiveeriodontalevaluationnewor$15stablishedatientD9110Palliative(mergency)reatmentofdentalpain$10D9310Consultation(iagnosticerviceprovidedbydentist$20otherthanpractitionerprovidingtreatment)D9430Officevisitforobservation/OSHA$10D9440Officevisitafterregularlyscheduledhours$50D9490Brokenappointmentfee$10min$15max RADIOGRAPHY/DIAGNOSTICDENTISTRD0210RayIntraoralCompleteSeries$0ncludingBitewingsD0220Rayntraoraleriapicalfirstfilm$0D0230Rayitraoraleriapicaleachadditionalfilm$0D0240RayntraoralocclusalFilm$0D0250Rayxtraoralirstfilm$0D0260Rayextraoralachadditionalfilm$0D0270Raybitewinginglefilm$0D0272Raybitewingwofilms$0D0274Raybitewingourfilms$24D0277Verticalbitewings,ourfilms*$28D0290Postantorlatskullandfacialfilm$150D0310Sialography$150D0320TMJ,Includinginjection$250D0321OtherTMJfilms,byreport$150D0322Tomographicurvey$150D0330Panoramicfilm(nottoreplaceFMX)$25D0340Cephalometricfilm,nonorthodontic$150D0350Diagnostichotographs$20D0415Bacterialogicstudies$0D0425Cariessusceptibilitytests$0D0460Pulpvitalitytests$10D0470Diagnosticcasts$25 PREVENTIVEDENTISTRYD1110Routineprophylaxisadult(onceevery6months)$0D1110Additionalroutineprophylaxisadult$45D1120Routineprophylaxischild(onceevery6months)$0(underageof16) PREVENTIVEDENTISTRY CONT'D D1120Additionalroutineprophylaxis(childrenunderthe$30ageof16D1201Topicalapplicationoffluoride$0Includingprophylaxis(underageof16)D1203Topicalapplicationoffluoride$0xcludingprophylaxis(underageof16)D1204Topicalapplicationoffluoride$20xcludingprophylaxis(adult)D1205opicalapplicationoffluoride$20ncludingprophylaxis(adult)D1310Nutritionalcounselingforcontrolofdentaldisease$0D1320Tobaccocounselingforthecontrolandprevention$0oforaldiseaseD1330OralhygieneInstructions$0D1351Applicationofsealantpertooth$15hildrenundertheageof16D1510Spacemaintainerfixedunilateral$120hildrenundertheageof16D1515Spacemaintainerfixedbilateral$175hildrenundertheageof16D1520Spacemaintainerremovable$160nilateralChildrenundertheageof16D1525Spacemaintainerremovable$250nilateralChildrenundertheageof16D1550Recementationofspacemaintainer$25 RESTORATIVEDENTISTRYD2140Amalgamonesurface,primaryorpermanent$50D2150Amalgamtwosurfaces,primaryorpermanent$55D2160Amalgamthreesurfaces,primaryorpermanent$60D2161Amalgamfoursurfaces,primaryorpermanent$75D2330Resinbasedcomposite1surface,anterior$45D2331Resinbasedcomposite2surfaces,anterior$65D2332Resinbasedcomposite3surfaces,anterior$75D2335Compositeresin4ormoresurfacesnvolving$88incisalangle(anterior)D2390Resinbasedcompositecrown,anterior$125D2391Resinbasedcomposite1surface,posterior$70D2392Resinbasedcomposite2surfaces,posterior$80D2393Resinbasedcomposite3surfaces,posterior$95D2394Resinbasedcomposite4+surfaces,posterior$120D2410Goldfoil1surface$75D2420Goldfoil2surfaces$95D2430Goldfoil3surfaces$125D2510Inlaymetallic1surface$300D2520Inlaymetallic2surfaces$320D2530Inlaymetallic3surfaces$340 RESTORATIVEDENTISTRY CONT'D D2542Onlaymetallic2surfaces$325D2543Onlaymetallic3surfaces$330D2544Onlaymetallic4ormoresurfaces$355D2610Inlayporcelain/ceramic1surface$325D2620Inlayporcelain/ceramic2surfaces$350D2630Inlayporcelain/ceramic3ormoresurfaces$375D2642Onlayporcelain/ceramic2surfaces$395D2643Onlayporcelain/ceramic3surfaces$415D2644Onlayporcelain/ceramic4ormoresurfaces$445D2650Inlayresinbasedcomposite,1surface$195D2651Inlayresinbasedcomposite,2surfaces$250D2652Inlayresinbasedcomposite,3ormoresurfaces$275D2662Onlayresinbasedcomposite,2surfaces$2502663Onlayresinbasedcomposite,3surfaces$275D2664Onlayresinbasedcomposite$290D2710Crownresin(Indirect)$210D2720Crownresinwithhighnoblemetal$455D2721Crownresinwithpredominantlybasemetal$405D2722Crownresinwithnoblemetal$425D2740Crownporcelain/ceramicsubstrate$525D2750Crownporcelainfusedtohighnoblemetal$499D2751Crownporcelainfusedtopredominantlybase$425metalD2752Crownporcelainfusedtonoblemetal$480D2780Crown3/4casthighnoblemetal$430D2781Crown3/4castpredominantlybasemetal$410D2782Crown3/4castnoblemetal$420D2783Crown3/4porcelain/ceramic$450D2790Crownfullcasthighnoblemetal$499D2791Crownfullcastpredominantlybasemetal$425D2792Crownfullcastnoblemetal$480D2799Provisionalcrown$130D2910Recementinlay$25D2920Recementcrown$25D2930Prefabricatedstainlesssteelcrownprimarytooth$95D2931Prefabricatedstainlesssteelcrownpermanent$95toothD2932Prefabricatedresincrown$95D2933Prefabricatedstainlesssteelcrownwithresin$145windowD2940Sedativefilling$40D2950Corebuildup,includinganypins$85D2951Pinretentionpertooth,inadditiontorestoration$20 SOL221PP10108SolsticeBenefits,Inc.isalicensedPrepaidLimitedHealthServicesOrganization,DiscountMedicalPlanOrganizationunderChapter636F.S.andThirdPartyAdministratorunderChapter626F.S.PlusPlanOne RESTORATIVEDENTISTRY CONT'D D2952CastpostandcoreInadditiontocrown$155D2953Eachadditionalcastpostsametooth$105D2954Prefabricatedpostandcoreinadditiontocrown$125D2955Postremoval(notinconjunctionwithendodontic$30therapy)D2957Eachadditionalprefabricatedpostsametooth$30D2960Labialveneer(resinlaminate)chairside$205D2961Labialveneer(resinlaminate)laborator$260D2962Labialveneer(porcelainlaminate)laboratory$425D2970Temporarycrown(fracturedtooth)$75D2980Crownrepair$95 ENDODONTICSERVICESD3110Pulpcapdirect(excludingfinalrestoration)$25D3120Pulpcapindirect(excludingfinalrestoration)$25D3220Therapeuticpulpotomy(excludingfinalrestoration)$75D3221Pulpaldebridement,primaryandpermanentteeth$95D3230Pulpaltherapy(resorbfilling)anterior,primary$80D3240Pulpaltherapy(resorbablefilling)posterior,primary$90D3310EndodontictherapyAnterior(excludingfinal$310restoration)D3320EndodontictherapyBicuspid(excludingfinal$375restoration)D3330EndodontictherapyMolar(excludingfinal$485restoration)D3331Treatmentofrootcanalobstruction,nonsurgical$85accessD3332Incompleteendodontictherapy;Inoperableor$125fracturedtoothD3333Internalrootrepairofperforationdefects$130D3346Retreatmentofpreviousrootcanaltherapy,$375AnteriorD3347Retreatmentofpreviousrootcanaltherapy,$410BicuspidD3348Retreatmentofpreviousrootcanaltherapy,$550MolarD3351Apexification/recalcificationInitialvisit$155D3352Apexification/recalcificationInterim$110medicationreplacementD3353Apexification/recalcificationFinalvisit$110D3410Apicoectomy/periradicularsurgeryanterior$275D3421Apicoectomy/periradicluarsurgery$325Bicuspid(Firstroot)D3425Apicoectomy/periradicularsurgery$350Molar(Firstroot)D3426Apicoectomy/periradicularsurgery$115Eachadditionalroot ENDODONTICSERVICES CONT'D D3430Retrogradefillingperroot$85D3450Rootamputationperroot$199D3470Intentionalreimplantation(includingsplinting)$180D3910Surgicalprocedureforisolationoftoothwith95rubberdamD3920Hemisection(includingrootremoval)$150D3950Canalpreparationandfittingofpreformeddowel$75orpost PERIODONTICSERVICESD4210Gingivectomy/gingivoplasty4+contiguousteeth$195perquadD4211Gingivectomy/gingivoplasty1to3teeth,perquad$50D4240Gingivalflapprocedure,includingrootplaning$3254ormoreteethD4241Gingivalflapprocedure,includingrootplaning$2501to3teethperquadD4245Apicallypositionedflap$150D4249Clinicalcrownlengtheninghardtissue$250D4260Osseoussurgery(Includingflapentryandclosure)$4504ormorecontiguousteethperquadD4261Osseoussurgery(Includingflapentryandclosure)$4201to3teethperquadrantD4263BonereplacementgraftfirstsiteInquadrant$200D4264BonereplacementgrafteachadditionalsiteIn$120quadrantD4266Guidedtissueregenerationresorbablebarrier,$191persiteD4267Guidedtissueregenerationnonresorbable$224barrier,persiteD4270Pediclesofttissuegraftprocedure$359D4271Freesofttissuegraftprocedure$340(includingdonorsitesurgery)D4273Subepithelialconnectivetissuegraftproedures$395D4274Distalorproximalwedgeprocedure$128D4341Periodontalscalingandrootplaning$804ormorecontiguousteethperquadrantD4342Periodontalscalingandrootplaning$601to3teeth,perquadD4355Fullmouthdebridementtoenable$80comprehensiveevaluationanddiagnosisD4381Localizeddeliveryofchemotherapeauticagentsvia$70acontrolledreleasevehicleintodiseasedcreviculartissue,pertoothD4910Periodontalmaintenance$55D4920Unscheduleddressingchange(bysomeoneother$25thanthetreatingdentaloffice) PROSTHODONTICSREMOVABLED5110Completedenturemaxillary$625 PROSTHODONTICSREMOVABLECONT'DD5120Completedenturemandibular$625D5130Immediatedenturemaxillary(including2relines)$695D5140Immediatedenturemandibular(including2$695relines)D5211Maxillarypartialdentureresinbase(including$450clasps)D5212Mandibularpartialdentureresinbase(including$490clasps)D5213Partialdenturemaxillarycastmetalacrylic$655D5214Partialdenturemandibularcastmetalacrylic$655D5410Adjustmentcompletedenturemaxillary$20D5411Adjustmentcompletedenturemandibular$20D5421Adjustmentpartialdenturemaxillary$20D5422Adjustmentpartialdenturemandibular$20D5510Repairbrokencompletedenturebase$75D5520Replacebrokentoothcompletedenture(each$70tooth)D5610Repairdentureresinbase$50D5620Repaircastframework$55D5630Repairorreplacebrokenclasp$55D5640Repairbrokenteethpertooth$45D5650Addtoothtoexistingpartialdenture$65D5660Addclasptoexistingpartialdenture$75D5710Rebasecompletemaxillarydenture$195D5711Rebasecompletemandibulardenture$195D5720Rebasemaxillarypartialdenture$175D5721Rebasemandibularpartialdenture$175D5730Relinecompletemaxillarydenture(chairside)$85D5731Relinecompletemandibulardenture(chairside)$85D5740Relinepartialmaxillarydenture(chairside)$65D5741Relinepartialmandibulardenture(chairside)$65D5750Relinecompletemaxillarydenture(laboratory)$150D5751Relinecompletemandibulardenture(laboratory)$150D5760Relinepartialmaxillarydenture(laboratory)$110D5761Relinepartialmandibulardenture(laboratory)$110D5810Interimcompletedenturemaxillary$250D5811Interimcompletedenturemandibular$250D5820Interimpartialdenturemaxillary$250D5821Interimpartialdenturemandibular$250D5850Tissueconditioningmaxillary$55D5851Tissueconditioningmandibular$55D5862Precisionattachment$150D5899Denturecleaning$0 SOL221PP10108SolsticeBenefits,Inc.isalicensedPrepaidLimitedHealthServicesOrganization,DiscountMedicalPlanOrganizationunderChapter636F.S.andThirdPartyAdministratorunderChapter626F.S.PlusPlanOne PROSTHODONTICS - FIXED D6210Ponticcasthighnoblemetal$499D6211Ponticcastpredominantlybasemetal$425D6212Ponticcastnoblemetal$480D6240Ponticporcelainfusedtohighnoblemetal$499D6241Ponticporcelainfusedtopredominantlybase$425metalD6242Ponticporcelainfusedtonoblemetal$480D6245Ponticporcelain/ceramic$495D6250Ponticresinwithhighnoblemetal$455D6251Ponticresinwithpredominantlybasemetal$405D6252Ponticresinwithnoblemetal$425D6545Retainercastmetalforresinbondedfixed$190prosthesisD6548Retainerporcelain/ceramicforresinbonded$230fixedprosthesisD6720Crownresinwithhighnoblemetal$455D6721Crownresinwithpredominantlybasemetal$405D6722Crownresinwithnoblemetal$425D6740Crownporcelain/ceramic$495D6750Crownporcelainfusedtohighnoblemetal$499D6751Crownporcelainfusedtopredominantlybase$425metalD6752Crownporcelainfusedtonoblemetal$480D6780Crown3/4casthighnoblemetal$430D6781Crown3/4castpredominantlybasemetal$410D6782Crown3/4castnoblemetal$420D6783Crown3/4porcelain/ceramic$410D6790Crownfullcasthighnoblemetal$499D6791Crownfullcastpredominantlybasemetal$425D6792Crownfullcastnoblemetal$480D6930Recementfixedpartialdenture$40D6940StressBreaker$125D6950Precisionattachment$195D6970Castpostandcoreinadditiontofixedpartial$170dentureretainerD6971Castpostaspartoffixedpartialdentureretainer$165D6972Prefabricatedpostandcoreinadditiontofixed$125partialdentureretainerD6973Corebuildupforretainer,includingpins$95D6975Copingmetal$95D6976Eachadditionalcastpostsametooth$75D6977Eachadditionalprefabricatedpostsametooth$75 ORALSURGERYD7110Singletoothextraction$70D7111Coronalremnantsdeciduoustooth$45D7140Extractionoferuptedtoothorexposedroot$70D7210Surgicalremovaloferuptedtooth$120D7220Removalofimpactedtoothsofttissue$125D7230Removalofimpactedtoothpartiallybony$145D7240Removalofimpactedtoothcompletelybony$165D7241Removalofimpactedtoothcompletelybony,$180withunusualsurgicalcomplicationsD7250Surgicalremovalofresidualtoothroots$95D7260Oroantralfistulaclosure$165D7270Toothreimplantation$56D7280Surgicalaccessofanunerruptedtooth$130D7281Surgicalexposureofimpactedorunerruptedtooth$130toaideruptionD7285Biopsyoforaltissuehard(bone,tooth)$120D7286Biopsyoforaltissuesoft(allothers)$95D7310Alveoloplasywithextractionsperquadrant$95D7320Alveoloplastywithoutextractionsperquadrant$130D7450Removalofodontogeniccystortumorupto1.25cm$65D7451Removalofodontogeniccystortumorgreaterthan$951.25cmD7510Incisionanddrainageofabscessintraoralsoft$55tissueD7960Frenulectomyseparateprocedur$110D7970Excisionofhyperplastictissueperarch$140D7470Removalofexotosis$80 MISCELLANEOUSSERVICESD8210Removableappliancetherapy$103D8220Fixedappliancetherapy$103D9215Localanesthesia$0D9220Generalanesthesiafirst30minutes$125D9221Generalanesthesiaeachadditional15minutes$55D9230Analgesianitrousoxide$20per1/2hourD9241Intravenoussedation/analgesiafirst30minutes$125D9242Intravenousconscioussedation/analgesiaeach$55additional15minutesD9630Oralirrigation/otherdrugs/medicament$15perquadrantD9910Applicationofdesensitizingmedicament$20D9940Occlusalguard$250D9950Occsalanalysismountedcase$75 (Excludingbleachingmaterialforhomeuse) MISCELLANEOUSSERVI CES CONT'D D9951Occlusaladjustmentlimited$25D9951Occlusaladjustmentcomplete$150D9972Cosmeticbleachingperarch$150D9972Cosmeticbleachingbotharches$275Foracopyofyourmemberhandbookpleasevisitwww.solsticebenefits.com toregisterand/orsignintoyouraccount.