2022 CarePartners of Connecticut Dental Option

dental
$19.00
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 performed by providers in the Dominion PPO Network and outside of the Dominion PPO Network are covered. Please refer to your Evidence of Coverage for more information.

Essentials

Premium

$19.00

Annual Deductible

$100 on restorative and major services
Prime Embedded Benefits
With Dental Option

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