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.
Lifetime Benefit Maximum:
N/A
Coverage Level:
Individual
Benefits Excluded from In Network MOOP:
N/A
Benefits Excluded from Out of Network MOOP:
N/A
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:
CI: N/A
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:
CI: N/A
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 Copayment AD
FDP Basic Dental Care - Child:
CP: $0-$100 Copyament AD
FDP Orthodontia - Child:
CP: $350 Copyament AD
FDP Cosmetic Orthodontia - Child:
CI: N/A
FDP Major Dental Care - Child:
CP: $20-$350 Copayment 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 Service Area Coverage:
N
FDP National Network:
N
FDP Network Name:
EssentialSmile 111
FDP Network URL:
Counties
Albany:
$8.19
Bronx:
$8.73
Broome:
$7.98
Cattaraugus:
$8.20
Cayuga:
$7.98
Chautauqua:
$8.20
Chemung:
$7.98
Clinton:
$7.76
Columbia:
$8.19
Cortland:
$7.98
Dutchess:
$8.01
Erie:
$8.20
Genesee:
$8.20
Jefferson:
$7.76
Kings:
$8.73
Monroe:
$8.09
Montgomery:
$8.19
Nassau:
$8.82
New York:
$8.73
Niagara:
$8.20
Oneida:
$7.76
Onondaga:
$7.98
Ontario:
$8.09
Orange:
$8.01
Oswego:
$7.76
Putnam:
$8.01
Queens:
$8.73
Rensselaer:
$8.19
Richmond:
$8.73
Rockland:
$8.73
Saratoga:
$8.19
Schenectady:
$8.19
Suffolk:
$8.82
Sullivan:
$8.01
Tompkins:
$7.98
Ulster:
$8.01
Warren:
$8.19
Westchester:
$8.73