Dental Plan Comparison
Weyco, Inc.
Dental Form - Frequently Asked Questions - Privacy Policy: HIPAA - Plan Document Dental Booklet
| D100/50/50 (maximum yearly coverage of $1,000 per person) | $50 applied to any Class II or Class III Service | Class I (preventative) Class II (basic) Class III (major) | 100% 50% 50% |
| D100/75/50/50 (maximum yearly coverage of $1,500 per person) | No Deductible | Class I (preventative) Class II (basic) Class III (major) Class IV (orthodontia) | 100% 75% 50% 50% |
| Benefit |
WEYCO D100/50/50 |
WEYCO D100/75/50/50 |
| Class I (Preventative Services) | 100% of Customary Reasonable Fee | 100% of Customary Reasonable Fee |
|
Diagnostic
Services
oral exams, 2 within a plan year - bitewing radiographs (x-rays) 2 within a plan year - full-mouth radiographs, every 36 months - other tests and lab exams |
Covered | Covered |
|
Preventative
Services
-
cleaning, 2 within the 12 month plan year - fluoride - space maintainers, under age 19 - dental sealant (for permanent first and second molars. One application once every five years for under age 20 years) |
Covered | Covered |
|
Palliative
Treatment - emergency treatment for the temporary relief of dental pain |
Covered | Covered |
| Class II (Basic Services) | 50% of Customary Reasonable Fee after annual deductible | 75% of Customary Reasonable Fee |
|
Restorative
Services - fillings, every 24 months - new inlays, onlays and crowns. Repair or restoration of inlays, onlays, crowns already in place - biopsy |
Covered | Covered |
|
Endodontic
Service - pulp capping - pulpotomy - root canal therapy - periapical treatment |
Covered | Covered |
|
Oral
Surgery - simple and surgical extractions - surgery of tooth socket - surgery of the soft tissue areas of the mouth - incision and drainage of intraoral abscess |
Covered | Covered |
| Basic Prosthodontic Services | Covered | Covered |
|
Adjunctive
General - general anesthesia and desensitizing medications - professional visits after office hours |
Covered | Covered |
| Class III (Major) Services | 50% of Customary Reasonable Fee after annual deductible | 50% of Customary Reasonable Fee |
|
Extended
Prosthodontic Services - removable dentures - fixed bridges - bridge pontics (artificial teeth) - abutment crowns for bridge construction Effective 7/1/2006: - dental implants - performed in a dental office. (Bridge procedures codes D06720 through D06792 for the same tooth as the implant are excluded). |
Covered | Covered |
| Class IV (Orthodontic) Services 19 years or younger | Not Covered | 50% of Customary Reasonable Fee |
|
Orthodontic
Services - appliance construction and installation - minor tooth guidance appliances - full-banding treatment - monthly, active treatment visits - habit-breaking appliances |
Not Covered | Covered Lifetime
maximum: $2,000 per member up to age
19. If started before 19 years of age,
they will pay until maximum is met, or until
treatment plan is done. Effective 7/1/2006: New Lifetime maximum: $2,000 per member up to age 19. |