Horizon Dental Option Plan
Horizon Dental wants you to get the most from your dental benefits.
You can save money when you receive care from a dentist who participates in your dental plan’s network. When you use in-network dentists, you generally only pay your copayment and any applicable in-network coinsurance or deductible. If you have out-of-network benefits and use an out-of-network dentist, your out-of-pocket costs will likely be higher. If you do not have out-of-network benefits, you are responsible for the entire cost of treatment.
Deductible
The deductible is the amount you must pay each year for covered charges before benefits are paid by your plan. The deductible applies to Treatment & Therapy, Endodontics, Periodontics, Oral Surgery, Prosthodontics, Crowns and Onlays.
| Individual | $50 |
| Family | $150 |
Benefit Period Maximum
The benefit period maximum is the most the dental plan will pay toward the cost of dental care within the benefit year. Preventive & Diagnostic, Treatment & Therapy, Endodontics, Periodontics, Oral Surgery, Prosthodontics, Crowns and Onlays
| Individual | $1,000 |
Orthodontics Eligibility
| Orthodontics | 60% |
| Orthodontics Maximum | $1,000 |
Coinsurance
Coinsurance is the fixed amount you must pay after you’ve paid the deductible for each medical visit to a participating doctor or other health care provider, usually at the time of service.
| Preventive Diagnostic | Strong Smile Rider | Excluded |
| Exam and Preventive Services Exams | 100% | |
| Fluoride Treatment | 100% | |
| Sealant Application | 100% | |
| Adult Prophylaxis | 100% | |
| X-rays (Bitewing & Full Mouth) | 100% | |
| Treatment and Therapy | Space Maintainers | 80% |
| Amalgam Restorations | 80% | |
| Composite Restorations – Anterior & Bicuspid | 80% | |
| Denture Adjustments | 80% | |
| Denture Repairs | 80% | |
| Simple Extractions | 80% | |
| Endodontics | Root Canal Therapy – Anterior & Bicuspid | 80% |
| Root Canal Therapy – Molar | 80% | |
| Periodontics | Scaling & Root Planing | 80% |
| Gingivectomy | 80% | |
| Periodontal Maintenance | 80% | |
| Osseous Surgery | 80% | |
| Oral Surgery | Surgical Extractions | 80% |
| Partial Bony Extractions | 80% | |
| Complete Bony Extractions | 80% | |
| Prosthodontics | Bridgework | 50% |
| Partial Dentures | 50% | |
| Crowns and Onlays | Crown – porcelain fused to high noble metal | 50% |
Eligibility
Dependent children of enrolled employees are covered to the age of 26.
Services are for illustrative purposes only. For complete listing of covered services, plan limitations, deductibles and maximums, consult your benefit booklet.
