MC-80 1-800-468-0466
Healthplex dental plans for all groups.
This dental plan is a great choice for employers or groups seeking:
- The same benefits as the Select plan but with lower copays
- Flexibility to use out-of-network dentists at any time
- A published schedule of out-of-net reimbursement amounts
In this managed care program, you and your covered family members select a dentist from the Comprehensive Directory of Participating Providers and receive all treatment from that dentist.
Should you require a specialist's care, you may be treated by a Comprehensive participating endodontist, periodontist, oral surgeon or orthodontist. Referrals are required to see a specialist. Services rendered by participating specialists follow the Comprehensive Schedule of Benefits.
Plans Underwritten by Dentcare Delivery Systems, Inc. in NY
Premiums vary based on plan options and group size.
Please contact a Healthplex sales representative at 1-800-468-0466 for a quote.
| ADA Code | Procedure | PATIENT COPAYMENT* |
|---|---|---|
| DIAGNOSTIC & PREVENTIVE SERVICES | ||
| 0150 | Comprehensive Oral Exam | $0.00 |
| 0210 | Full Mouth Series X-rays | $0.00 |
| 0220 | Periapical, First Film | $0.00 |
| 0274 | Bitewings, Four Films | $0.00 |
| 1110/1120 | Cleaning, Adult/Child | $0.00 |
| 1208 | Fluoride Treatment | $0.00 |
| 1351 | Sealant, Per Tooth | $0.00 |
| BASIC | ||
| 2140 | Amalgam, 1 Surface | $0.00 |
| 2150 | Amalgam, 2 Surfaces | $0.00 |
| 2160 | Amalgam, 3 Surfaces | $0.00 |
| 2161 | Amalgam, 4+ Surfaces | $0.00 |
| 2330 | Resin-Based Composite, 1 Surface, Anterior | $0.00 |
| 2331 | Resin-Based Composite, 2 Surfaces, Anterior | $0.00 |
| 2332 | Resin-Based Composite, 3 Surfaces, Anterior | $0.00 |
| 2335 | Resin-Based Composite, 4+ Surfaces, Anterior | $0.00 |
| 2391 | Resin-Based Composite, 1 Surface, Posterior | $30.00 |
| 2392 | Resin-Based Composite, 2 Surfaces, Posterior | $40.00 |
| 2393 | Resin-Based Composite, 3 Surfaces, Posterior | $60.00 |
| 2394 | Resin-Based Composite, 4+ Surfaces, Posterior | $75.00 |
| 3220 | Pulpotomy | $90.00 |
| 3310 | Root Canal Therapy, Anterior | $125.00 |
| 3320 | Root Canal Therapy, Bicuspid | $250.00 |
| 3330 | Root Canal Therapy, Molar | $300.00 |
| 3410 | Apicoectomy, Per Root | $100.00 |
| 4210 | Gingivectomy, Per Quad | $200.00 |
| 4260 | Osseous Surgery, Per Quad | $200.00 |
| 4341 | Scaling/Root Planing, Per Quad | $50.00 |
| 7140 | Routine Extraction | $50.00 |
| 7210 | Surgical Extraction | $75.00 |
| 7220 | Soft Tissue Impaction | $100.00 |
| 7230 | Partial Bony Impaction | $125.00 |
| 7240 | Full Bony Impaction | $175.00 |
| 7310 | Alveolectomy | $50.00 |
| 9110 | Palliative Treatment | $0.00 |
| MAJOR | ||
| 2750 | Porcelain with Metal Crown | $250.00 |
| 2790 | Full Cast Crown | $250.00 |
| 2920 | Recementation, Crown/Bridge | $0.00 |
| 2930 | Stainless Steel Crown (Primary Tooth) | $250.00 |
| 2952 | Post and Core, Casted | $100.00 |
| 5110/5120 | Complete Upper/Lower Denture | $250.00 |
| 5213/5214 | Partial Upper or Lower Denture, Cast Base | $250.00 |
| 5410 | Denture Repairs Including Adding Teeth | $250.00 |
| 5730/5740 | Relines | $250.00 |
| 6240 | Porcelain w/Metal Pontic | $250.00 |
| 6750 | Porcelain/Metal Abutment | $250.00 |
| 6790 | Full Cast Abutment | $250.00 |
| ORTHODONTICS | ||
| Copays range from $0 to $3,000. Please refer to Member ID card for plan specification. | ||
Members must use dentists who participate in the Comprehensive Panel.
Referrals are required to see a dental specialist.
Members are responsible for all costs not covered by this dental plan.
* This co-payment schedule contains a general description of your Dental Care program for your use as a convenient reference. Due to certain Exclusions and/or Limitations, all member copayments may not be applicable. Prior to receiving any treatment, please obtain the Certificate of Insurance from your benefit administrator for Exclusions and Limitations. All benefits are governed by the provisions of your group's contract.
How do I enroll?
Please call our Sales and Marketing Department at 1-800-468-0466, or send us an email at sales@healthplex.com.
How do I receive dental care and benefits?
Call your participating dentist for an appointment after you receive your ID card and identify yourself as a Comprehensive MC-80 Plan member. Visits for routine dental care will be scheduled within a few weeks of your initial phone call. If you have a dental emergency, you will be given an appointment within 24 hours. Should you be away from home with a dental problem, you will be reimbursed up to $50 for emergency care only.
Will I be satisfied with the services of my participating dentist?
All dentists in our network are credentialed by Healthplex.
We conduct site visits to ensure all offices are well equipped, adequately staffed and are following proper sterilization techniques.
If you have a problem with your dentist, we will rectify the situation or refund your premium.
What expenses will I have in this plan for general dentistry and specialty care?
Your costs are clearly noted in the MC-80 Schedule of Benefits.
Services listed with "No Charge" are rendered with no out-of-pocket expense.
Other services have co-payments that you pay directly to your participating dentist.
Referral Forms are not necessary when visiting Comprehensive participating specialists.
Just present your Comprehensive identification card.
For other questions about the plan, please call our Sales and Marketing Department at 1-800-468-0466, or send us an email at sales@healthplex.com.