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2021 CarePartners of Connecticut Dental Option
$15.00 per month
About the plan
The CarePartners of Connecticut Dental Option is provided by Dominion National, a leading administrator of dental benefits. The plan includes access to thousands of dentists across the region. Our CareAdvantage Prime and CareAdvantage Premier plans have limited embedded preventive and restorative coverage, but this plan gives you the comprehensive coverage you need. No waiting periods!
If you are a current member and would like to add the 2021 CarePartners of Connecticut Dental Option to your plan, call 1-844-267-1361 (TTY: 711).
Essentials
Premium
$15.00
Annual Deductible
$100 on restorative and major services
$15.00
$100 on restorative and major services
Prime/Premier (embedded)
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.
$25
$25
Periodic oral evaluation
Two per year.
$25
$25
Emergency oral evaluation problem focused exams
Once every 12 months.
50% after deductible
20% after deductible
Intra-oral X-ray image of the entire mouth
Panoramic image. Once every 60 months.
50% after deductible
20% after deductible
Intra-oral X-ray image of the entire mouth
Full mouth series. Once every 60 months.
50% after deductible
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.
$25
$25
Single tooth X-ray images
As needed.
50% after deductible
20% after deductible
Comprehensive oral exam
Including the initial dental history and charting of teeth. Once every 36 months.
$25
$25
Periodic oral evaluation
Two per year.
$25
$25
Emergency oral evaluation problem focused exams
Once every 12 months.
50% after deductible
20% after deductible
Intra-oral X-ray image of the entire mouth
Panoramic image. Once every 60 months.
50% after deductible
20% after deductible
Intra-oral X-ray image of the entire mouth
Full mouth series. Once every 60 months.
50% after deductible
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.
$25
$25
Single tooth X-ray images
As needed.
50% after deductible
20% after deductible
Prime/Premier (embedded)
With Dental Option
Preventive Services
Prophylaxis (routine cleaning, scaling, and polishing of teeth)
Two per year.
$25
$25
Periodontal cleaning
Once every 6 months following active periodontal therapy, not to be combined with regular cleanings.
50% after deductible
20% after deductible
Prophylaxis (routine cleaning, scaling, and polishing of teeth)
Two per year.
$25
$25
Periodontal cleaning
Once every 6 months following active periodontal therapy, not to be combined with regular cleanings.
50% after deductible
20% after deductible
Prime/Premier (embedded)
With Dental Option
Restorative Services
Silver fillings and white fillings (front teeth)
Once every 24 months per surface per tooth.
50% after deductible
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.
50% after deductible
20% after deductible
Inlays
Once per tooth per 84 months.
100% after deductible
50% after deductible
Protective restorations
Once per tooth.
100%
50% after deductible
Silver fillings and white fillings (front teeth)
Once every 24 months per surface per tooth.
50% after deductible
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.
50% after deductible
20% after deductible
Inlays
Once per tooth per 84 months.
100% after deductible
50% after deductible
Protective restorations
Once per tooth.
100%
50% after deductible
Prime/Premier (embedded)
With Dental Option
Oral Surgery
Simple extractions
Once per tooth.
50% after deductible
20% after deductible
Surgical extractions
Once per tooth.
100%
50% after deductible
Simple extractions
Once per tooth.
50% after deductible
20% after deductible
Surgical extractions
Once per tooth.
100%
50% after deductible
Prime/Premier (embedded)
With Dental Option
Periodontics
Periodontal surgery
One surgical procedure per lifetime; gingivectomy or gingivoplasty and osseous surgery covered as needed.
100%
50% after deductible
Scaling and root planing
Once in 24 months, per quadrant.
50% after deductible
20% after deductible
Bone grafts and guided tissue regeneration
Once per lifetime.
100%
50% after deductible
Periodontal surgery
One surgical procedure per lifetime; gingivectomy or gingivoplasty and osseous surgery covered as needed.
100%
50% after deductible
Scaling and root planing
Once in 24 months, per quadrant.
50% after deductible
20% after deductible
Bone grafts and guided tissue regeneration
Once per lifetime.
100%
50% after deductible
Prime/Premier (embedded)
With Dental Option
Endodontics
Root canal treatment
Once per tooth per lifetime.
100%
50% after deductible
Retreatment root canal therapy
Once per tooth per lifetime after 24 months of initial root canal therapy.
100%
50% after deductible
Apicoectomy
Covered as needed.
100%
50% after deductible
Root canal treatment
Once per tooth per lifetime.
100%
50% after deductible
Retreatment root canal therapy
Once per tooth per lifetime after 24 months of initial root canal therapy.
100%
50% after deductible
Apicoectomy
Covered as needed.
100%
50% after deductible
Prime/Premier (embedded)
With Dental Option
Prosthetic Maintenance
Bridge or denture repair
Once every 24 months per bridge or denture.
100%
50% after deductible
Tissue conditioning
One treatment per denture every 84 months.
100%
50% after deductible
Adding teeth to existing partial or full dentures
Once per tooth, per denture, per 24 months.
100%
50% after deductible
Rebase or reline of dentures
Once per denture every 24 months.
100%
50% after deductible
Recement of crowns and onlays
Once per tooth per 12 months.
100%
50% after deductible
Bridge or denture repair
Once every 24 months per bridge or denture.
100%
50% after deductible
Tissue conditioning
One treatment per denture every 84 months.
100%
50% after deductible
Adding teeth to existing partial or full dentures
Once per tooth, per denture, per 24 months.
100%
50% after deductible
Rebase or reline of dentures
Once per denture every 24 months.
100%
50% after deductible
Recement of crowns and onlays
Once per tooth per 12 months.
100%
50% after deductible
Prime/Premier (embedded)
With Dental Option
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.
50% after deductible
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.
100%
50% after deductible
Minor treatment for pain relief
Only if no services other than exam and X-rays were performed on the same date of service.
50% after deductible
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.
100%
50% after deductible
Prime/Premier (embedded)
With Dental Option
Prosthodontics
Dentures
Complete or partial dentures; one per arch within 84 months.
100%
50% after deductible
Fixed bridges
Once per 84 months.
100%
50% after deductible
Temporary partial dentures
Once per 84 months.
100%
50% after deductible
Dentures
Complete or partial dentures; one per arch within 84 months.
100%
50% after deductible
Fixed bridges
Once per 84 months.
100%
50% after deductible
Temporary partial dentures
Once per 84 months.
100%
50% after deductible
Prime/Premier (embedded)
With Dental Option
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.
100%
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.
100%
50% after deductible
Crowns and onlays-initial placement
When teeth cannot be restored with regular fillings due to fracture or decay. Once within 84 months per tooth.
100%
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.
100%
50% after deductible
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.