Plan
Plan Name:
EssentialSmile 111 NS INN Family Dental Dep 29
Issuer Name:
Solstice Health Insurance Company
HIOS ID:
85427NY0010002
Annual Benefit Maximum:
N/A
Plan Brochure Link:
Out of Network Coverage:
N
Dental Plan Type
Dental Plan Type:
Adult & Family Dental Plan
Plan Information
Dep Age:
Age 29
Plan Type:
EPO
Standard or Non-Standard Plan:
Non-Standard
Waiting Periods:
None
Deductible Adult Individual:
$50
Limit Description:
1 exam per 6 months.
Limits on Services:
Yes
Lifetime Benefit Maximum:
N/A
Coverage Level:
Individual
FDP In Network Cost Sharing Adult Benefits
FDP Office Visit With No Additional Services - Adult:
CP: $0 AD
FDP Oral Evaluation - Adult:
CP: $0 AD
FDP Complete Set of X-Rays - Adult:
CP: $0 AD
FDP Topical Fluoride - Adult:
CP: $15-30 AD
FDP Polishing - Adult:
CP: $0 AD
FDP Sealant (per tooth) - Adult:
CP: $43 AD
FDP Spacers - Adult:
Not covered
FDP Simple Extraction - Adult:
CP: $65-75 AD
FDP Fillings - Adult:
CP: $25-150 AD
FDP Single Restoration Crowns - Adult:
CP: $300 AD
FDP Pulp Cap - Adult:
CP: $50 AD
FDP Bonding - Adult:
CP: $15-$270 AD
FDP Root Canal - Adult:
CP: $85-$660 AD
FDP In Network Cost Sharing Adult Benefits
FDP MOOP Adult Individual:
None
FDP Deductible 2+ Adult Members:
$50 per member
FDP MOOP 2+ Members:
None
FDP Additional In Network Cost Sharing Adult Benefits
FDPA Scaling - Adult:
CP: $45-$120 AD
FDPA Gingivectomy or Gingivoplasty - Adult:
CP: $95 AD
FDPA Gum Surgery - Adult:
CP: $230-$635 AD
FDPA Routine Braces - Adult:
CP: $2,000-$3,850 AD
FDPA Partial Dentures - Adult:
CP: $275-$500 AD
FDPA Complete Dentures - Adult:
CP: $425 AD
FDPA Dental Implants - Adults:
CP: $475-$1050 AD
FDPA Bridges - Adults:
CP: $340-$350 AD
FDPA Veneers - Adult:
CP: $280-$605 AD
FDPA TMJ - Adult:
Not covered
FDP In Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual:
$50
FDP MOOP Pediatric Individual:
$400 One (1) Member under age 19
FDP Deductible Pediatric 2+ Children:
$50 per member
FDP MOOP Pediatric 2+ Children:
$800 Two (2) or more Members under age 19
FDP Dental Check-Up - Child:
CP: $0 AD
FDP Basic Dental Care - Child:
CP: $0 -$100 AD
FDP Orthodontia - Child:
CP: $350 AD
FDP Cosmetic Orthodontia - Child:
Not covered
FDP Major Dental Care - Child:
CP: $20-$350 AD
FDP Out of Network Cost Sharing Adult Benefits
FDP Deductible Adult Individual (Out of Network Cost Sharing Adult Benefits):
N/A
FDP MOOP Adult Individual (Out of Network Cost Sharing Adult Benefits):
None
FDP Deductible 2+ Members (Out of Network Cost Sharing Adult Benefits):
N/A
FDP MOOP 2+ Members (Out of Network Cost Sharing Adult Benefits):
None
FDP Office Visit With No Additional Services - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Oral Evaluation - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Complete Set of X-Rays - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Prophylaxis - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Topical Fluoride - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Polishing - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Sealant (per tooth) - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Spacers - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Simple Extraction - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Fillings - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Single Restoration Crowns - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Pulp Cap - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Bonding - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Root Canal - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Scaling - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Additional Out of Network Cost Sharing Adult Benefits
FDP Gingivectomy or Gingivoplasty - Adult:
Not covered
FDP Gum Surgery - Adult:
Not covered
FDP Tissue Grafting - Adult:
Not covered
FDP Routine Braces - Adult:
Not covered
FDP Partial Dentures - Adult:
Not covered
FDP Complete Dentures - Adult:
Not covered
FDP Dental Implants - Adults:
Not covered
FDP Bridges - Adults:
Not covered
FDP Veneers - Adult:
Not covered
FDP TMJ - Adult:
Not covered
FDP Out of Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
N/A
FDP MOOP Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Deductible Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
N/A
FDP MOOP Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Dental Check-Up - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Basic Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Cosmetic Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Major Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Network Information (Family Dental)
FDP Out of Country Coverage:
N
FDP Out of Country Coverage Description:
N/A
FDP Out of Service Area Coverage:
N
FDP Out of Service Area Coverage Description:
N/A
FDP National Network:
N
FDP Network Name:
EssentialSmile EPO
FDP Network URL:
Counties
Albany:
$8.52
Bronx:
$32.49
Broome:
$8.30
Cattaraugus:
$8.54
Cayuga:
$8.30
Chautauqua:
$8.54
Chemung:
$8.30
Clinton:
$8.07
Columbia:
$8.52
Cortland:
$8.30
Dutchess:
$8.34
Erie:
$8.54
Genesee:
$8.54
Jefferson:
$8.07
Kings:
$32.49
Monroe:
$8.41
Montgomery:
$8.52
Nassau:
$9.18
New York:
$32.49
Niagara:
$8.54
Oneida:
$8.07
Onondaga:
$8.30
Ontario:
$8.41
Orange:
$8.34
Oswego:
$8.07
Putnam:
$8.34
Queens:
$32.49
Rensselaer:
$8.52
Richmond:
$32.49
Rockland:
$32.49
Saratoga:
$8.52
Schenectady:
$8.52
Suffolk:
$9.18
Sullivan:
$8.34
Tompkins:
$8.30
Ulster:
$8.34
Warren:
$8.52
Westchester:
$6.92