Coverage For Your Dental Care Needs.
Research shows that oral health and overall health are closely related. So when you keep your teeth healthy, you are also helping to keep your body healthy.
Our PPO Dental plan offers coverage options for preventive/diagnostic, basic and major restorative services through Careington’s Maximum Care network of 200,000 providers.
Applying is simple and can be completed in minutes.
PPO Dental At A Glance
100% coverage on both plans for many preventive services like cleanings, X-rays and oral exams1
Pays up to $1,500 per person, per calendar year for covered services on the Premiere Plan.
Large network of dentists and specialists to choose from. Visit ChesapeakePlus.com to view a list of in-network providers1
Affordable premiums that do not increase as you get older with Basic coverage starting at $1350 per month2
“Careington Benefit Solutions, a CAREINGTON International Company administers the dental insurance plans on behalf of Chesapeake through their extensive Maximum
Care Network. | 2
Premium for an adult Basic PPO Dental plan”
Benifits-Network Provider
Basic
Premiere
MONTHLY PREMIUMS
See the following pages for Type I, Type II and Type III covered services details | The chart above is only an illustration of benefit and premium options per covered
person. | Visit ChesapeakePlus.com to view a list of in-network providers. | *Waiting periods are waived for an insured person previously covered under full dental
coverage, provided such prior coverage was in effect for at least 12 consecutive months and is continuous to a date no more than 63 days prior to your application
date.
Certain services include limitations. Benefits are reduced for non-network providers. See Policy for details. | Note: If an insured person opts to receive dental services or procedures that are not covered expenses under the Policy, a network provider dentist may charge his or her usual and customary rate for such services or procedures. Prior to providing an insured person dental services or procedures that are not covered expenses, the dentist should provide a treatment plan that includes each anticipated service or procedure to be provided and the estimated cost of each service or procedure. To fully understand the coverage provided under the Policy, you should read your Policy carefully.
Type I Covered Services:
Premiere and Basic plans include the following services with
no waiting period:
Preventive:
• Prophylaxis – once every six months
• Topical Flouride – once every 12 months, up to age 16
• Sealants – once every 36 months, up to age 16
Diagnostic:
• Oral evaluations – once every six months
• Bitewing X-rays – once every 12 months
• Vertical bitewings – once every 36 months
• Diagnostic casts
Preventive:
• Space maintainers – up to age six
Diagnostic:
• Intraoral films, extraoral films and panoramic film –
once every 36 months
Restorative:
• Amalgam, primary or permanent & resin-based composite
Adjunctive:
• Palliative (emergency) treatment of pain
• Fixed partial denture sectioning
• Local anesthesia
• Analgesia – up to age 13
• Inhalation of nitrous oxide
• Occlusion analysis and occlusion adjustment
1 Type I services for Premiere and Basic plans are covered at 100% in-network and 80% non-network. | 2
Type II services for Premiere plan are covered at 80% in-network and 60%
non-network. Type II services for Basic plan are covered at 50% for both in-network and non-network.
Type III Covered Services:
Premiere plan only includes the following services with a 12 month waiting period, unless stated otherwise:
Restorative:
• Inlays and onlays (and recementing, once every 12 months after a six month waiting period)
• Crowns; cast posts and core buildups
• Pin retention in addition to restoration – up to two procedures every 12 months
• Sedative fillings
Endodontics:
• Pulp caps; therapeutic pulpotomy; pulpal therapy
• Root canal or endodontic therapy
Oral Surgery:
• Extraction of erupted tooth; removal of impacted tooth
• Tooth transplantation
• Alveoloplasty
• Removal of cyst/tumor 1.25 cm and greater
• Incision and drainage of abscess
Prosthodontics:
• Complete and partial dentures – once every five years for complete dentures to replace missing/broken teeth
• Adjustment and repair of dentures
Periodontics:
• Gingivectomy/gingivoplasty – once every 36 months
• Gingival flap procedure and osseous surgery – each limited to once every 36 months
• Soft tissue graft procedures
• Periodontal scaling and root planning – limited to four separate quadrants every two years
• Full-mouth debridement to enable evaluation and diagnosis – once every 36 months
1 Type III services for Premiere plan only are covered at 60% in-network and 50% non-network.
For a complete listing of benefits, exclusions and limitations, please refer to your Policy. In the event of any discrepancies contained in this brochure, the terms and conditions
contained in the Policy documents shall govern. Dental Insurance Preferred Provider Organization (PPO) Policy, Form CH-26121-IP (01/12) FL. | The information contained herein is
accurate at the time of publication. This brochure provides only summary information.
Notice to Our Customers About Supplemental Insurance
• The supplemental plan discussed in this document is separate from any health insurance
coverage you may have purchased with another insurance company.
• This plan provides optional coverage for an additional premium. It is intended to supplement your
health insurance and provide additional protection.
• This plan is not required in order to purchase health insurance with another insurance company.
• This plan should not be used as a substitute for comprehensive health insurance coverage. It is
not considered Minimum Essential Coverage under the Affordable Care Act.
Other Important Information
EXCLUSIONS AND LIMITATIONS
We will not provide any benefits for charges arising directly or indirectly, in whole or in part, from:
For Basic and Premiere Plans: Treatment, care, services or supplies for which benefits are not specifically provided for in the Policy | Charges exceeding the maximum
benefit amount, if any | Attempted suicide or any intentionally self-inflicted injury | Directly or indirectly engaging in illegal activity| Treatment of disturbances of the
temporomandibular joint (TMJ) | A service not furnished by a dentist, unless by a dental hygienist under the dentist’s supervision and x-rays are ordered by the dentist | Plaque
control, completion of claim forms; broken appointments, prescription or take-home fluoride, or diagnostic photographs | Oral/facial images, including intra- and extra-oral
images | Pulp vitality tests | Chairside, labial veneers (laminates) | Regional block anesthesia | Hospital, house or extended care facility calls | Office visits for the purpose of
observation, during or after regularly scheduled hours | Office visits outside of regularly scheduled hours | Enamel microabrasions | Services not completed by the end of the
month in which coverage terminates | Procedures that are begun, but not completed | Those services for which there would be no charge in the absence of insurance or for any
service or treatment provided without charge | Services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring
while on full-time active duty in the armed forces of any country or combination of countries | Care or treatment of a condition for which benefits are payable under any Workers’
Compensation Act or similar law | Orthodontic procedures | Covered expenses for which an insured person is not legally obligated to pay | Experimental/Investigational treatment
For Basic Plan Only: Cosmetic procedures
For Premiere Plan Only: Cosmetic procedures, unless due to an injury or for congenital/developmental malformation. Facing on crowns, or pontics, posterior to the second
bicuspid is considered cosmetic | The replacement of full and partial dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function | Implants;
replacement of lost or stolen appliances; replacement of orthodontic retainers; athletic mouth-guards; precision or semi-precision attachments; denture duplication; or splinting
| Replacement of any prosthetic appliance, crown, inlay, or onlay restoration, or fixed bridge within 5 years of the date of the last replacement, unless due to an injury | Post
removals unless in conjunction with endodontic therapy | Intentional re-implantation, including necessary splinting | Surgical procedure for isolation of tooth with rubber dam |
Canal preparation and fitting of performed dowel or post | An initial placement of a partial or full removable denture or fixed bridgework if it involves the replacement of one or
more natural teeth lost before coverage was effective under the Policy. This limitation does not apply if replacement includes a natural tooth extracted while covered under the
Policy.
Coverage Information:
RENEWABILITY: Your Policy is conditionally renewable, subject to Chesapeake’s right to discontinue or terminate coverage as provided in the termination of coverage section of the Policy.
PREMIUM CHANGES: Chesapeake reserves the right to change the table of premiums, on a class basis, becoming due under the Policy at any time and from time to time; provided, Chesapeake has given you written notice of at least 45 days prior to the effective date of the new rates.
TERMINATION OF COVERAGE: Your coverage will terminate and no further benefits will be payable under the Policy or any attached riders, if any: | At the end of the period for which premium has been paid | If your mode of premium is monthly, at the end of the period through which premium has been paid following our receipt of your request of termination | If your mode of premium is other than monthly, upon the next monthly anniversary day following our receipt of your request of termination. Premium will be refunded for any amounts paid beyond the termination date | On the date of fraud or misrepresentation by you | On the date we elect to discontinue this plan or type of coverage | On the date we elect to discontinue all coverage in your state | On the date an insured person is no longer a permanent resident of the United States.
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