DentaCert Value Plan Details
P
reventive Care - No waiting Period
Routine Oral Exam
Limit one visit per 12 months
NO COST
Comprehensive Oral Exam
1 per year, per member
NO COST
Consultation
1 per year, per member, other than treating doctor
NO COST
Problem Focused Exams
1 per year, per member
NO COST
Prophylaxis
Cleaning & scaling, 100% paid, 1 per year, per member
NO COST
Fluoride
100% paid, 1 per year, per membe
r
for dependent children under age 16
NO COST
Diagnostic Care - No waiting Period
Intra-Oral Occlusal Film
Limit one visit per 12 months
NO COST
Bitewing X-Rays
100% paid, 1 per year, per member, up to set of 4
NO COST
Full Mouth X-Rays
100% paid, 1 per 36 months, per member
NO COST
Periapicals
100% paid
NO COST
Orthodontics & Prosthodontics - No waiting Period (Network Savings)
Basic
Major and All Other Dental Procedures - (Network Savings)
O
rthodontic treatment for dependent children under age 19
Discounted 15%-50%
Annual Maximum Benefit
N/A
2009- ICB America -
