2021 CarePartners of Connecticut Dental Option

$15.00

per month

About the Plan

Interested in adding the CarePartners of Connecticut Dental Option to your plan?

It's easy to add the CarePartners of Connecticut Dental Option to your plan. Just call 1-844-267-1361 (TTY: 711) and one of our Licensed Medicare Agents can answer any questions you have and enroll you in just a few minutes.

The CarePartners of Connecticut Dental Option is in addition to your medical coverage with CarePartners of Connecticut. It is not automatically included. To add the Dental Option to your plan, call 1-844-267-1361. The plan is administered by Dominion Dental Services, Inc., which operates under the trade name Dominion National. Services must be performed by providers in the Dominion PPO Network. Please refer to your Evidence of Coverage for more information.

Essentials

Premium

$15.00

Annual Deductible

$100 on restorative and major services

Diagnostic Services

The charts displayed below represent what the member pays for dental services such as diagnostic, preventive, restorative, oral surgery, prosthodontics, and more.

Comprehensive oral exam

Including the initial dental history and charting of teeth. Once every 36 months.

Without Option (embedded)'

$25

With Option

$25

Periodic oral evaluation

Two per year.

Without Option (embedded)'

$25

With Option

$25

Emergency oral evaluation problem focused exams

Once every 12 months.

Without Option (embedded)'

50% after deductible

With Option

20% after deductible

Intra-oral X-ray image of the entire mouth

Panoramic image. Once every 60 months.

Without Option (embedded)'

50% after deductible

With Option

20% after deductible

Intra-oral X-ray image of the entire mouth

Full mouth series. Once every 60 months.

Without Option (embedded)'

50% after deductible

With Option

20% after deductible

Intra-oral bitewing X-ray images

X-rays of the crowns of the teeth when oral conditions indicate need. Two per year.

Without Option (embedded)'

$25

With Option

$25

Single tooth X-ray images

As needed.

Without Option (embedded)'

50% after deductible

With Option

20% after deductible

Preventive Services

Prophylaxis (routine cleaning, scaling, and polishing of teeth)

Two per year.

Without Option (embedded)'

$25

With Option

$25

Periodontal cleaning

Once every 6 months following active periodontal therapy, not to be combined with regular cleanings.

Without Option (embedded)'

50% after deductible

With Option

20% after deductible

Restorative Services

Silver fillings and white fillings (front teeth)

Once every 24 months per surface per tooth.

Without Option (embedded)'

50% after deductible

With Option

20% after deductible

White fillings (back teeth)

Covered only for single surfaces. Once every 24 months per surface, per tooth; multi-surfaces will be processed as a silver filling, and the patient is responsible up to the contracted fee.

Without Option (embedded)'

50% after deductible

With Option

20% after deductible

Inlays

Once per tooth per 84 months.

Without Option (embedded)'

100% after deductible

With Option

50% after deductible

Protective restorations

Once per tooth.

Without Option (embedded)'

100%

With Option

50% after deductible

Oral Surgery

Simple extractions

Once per tooth.

Without Option (embedded)'

50% after deductible

With Option

20% after deductible

Surgical extractions

Once per tooth.

Without Option (embedded)'

100%

With Option

50% after deductible

Periodontics

Periodontal surgery

One surgical procedure per lifetime; gingivectomy or gingivoplasty and osseous surgery covered as needed.

Without Option (embedded)'

100%

With Option

50% after deductible

Scaling and root planing

Once in 24 months, per quadrant.

Without Option (embedded)'

50% after deductible

With Option

20% after deductible

Bone grafts and guided tissue regeneration

Once per lifetime.

Without Option (embedded)'

100%

With Option

50% after deductible

Endodontics

Root canal treatment

Once per tooth per lifetime.

Without Option (embedded)'

100%

With Option

50% after deductible

Retreatment root canal therapy

Once per tooth per lifetime after 24 months of initial root canal therapy.

Without Option (embedded)'

100%

With Option

50% after deductible

Apicoectomy

Covered as needed.

Without Option (embedded)'

100%

With Option

50% after deductible

Prosthetic Maintenance

Bridge or denture repair

Once every 24 months per bridge or denture.

Without Option (embedded)'

100%

With Option

50% after deductible

Tissue conditioning

One treatment per denture every 84 months.

Without Option (embedded)'

100%

With Option

50% after deductible

Adding teeth to existing partial or full dentures

Once per tooth, per denture, per 24 months.

Without Option (embedded)'

100%

With Option

50% after deductible

Rebase or reline of dentures

Once per denture every 24 months.

Without Option (embedded)'

100%

With Option

50% after deductible

Recement of crowns and onlays

Once per tooth per 12 months.

Without Option (embedded)'

100%

With Option

50% after deductible

Adjunctive Services

Services provided in conjunction with the primary treatment.

Minor treatment for pain relief

Only if no services other than exam and X-rays were performed on the same date of service.

Without Option (embedded)'

50% after deductible

With Option

20% after deductible

Local anesthesia and inhalation of nitrous oxide/analgesia, anxiolysis

Local Anesthesia and inhalation of nitrous oxide/analgesia, anxiolysis are provided in conjunction with covered oral surgery or periodontal surgery and are integral to the primary treatment.

Without Option (embedded)'

100%

With Option

50% after deductible

Prosthodontics

Dentures

Complete or partial dentures; one per arch within 84 months.

Without Option (embedded)'

100%

With Option

50% after deductible

Fixed bridges

Once per 84 months.

Without Option (embedded)'

100%

With Option

50% after deductible

Temporary partial dentures

Once per 84 months.

Without Option (embedded)'

100%

With Option

50% after deductible

Major Restorative

Crowns and onlays-initial placement

When teeth cannot be restored with regular fillings due to fracture or decay. Once within 84 months per tooth.

Without Option (embedded)'

100%

With Option

50% after deductible

Post and core or crown buildup

When needed to retain a crown on a tooth with excessive breakdown due to caries and/or fractures. Once per tooth every 84 months.

Without Option (embedded)'

100%

With Option

50% after deductible