Solstice Dental PPO 2000


(Available in all 50 states)
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January 15, 2025 | 06:49 am
IP Address: 216.18.204.202
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Bigger Value For A Brighter Smile.

Quality, affordable dental care… It’s that simple. Solstice dental plans offer rich plans and unbeatable savings with the security of knowing that you will be protected from hidden fees and surprises. Plus, our large open-access provider network means that you’ll never have to deal with frustrating roster restrictions again. Now that’s something to smile about. 

Plan includes $5,000 term life and $5000 AD&D.



Issue ages: 18 to Any Age

Dependent children age: Last day of the year they turn 26

Plan includes $5,000 term life and $5000 AD&D.

Provider Lookup (Solstice PPO) http://www.solsticebenefits.com/provider-search.aspx (Solstice PPO)
Find a Dental Provider (How To) PDF
Plan Summary & Limitations, Non-Covered Services, and Exclusions PDF


  NON-ORTHODONTICS ORTHODONTICS
  NETWORK OUT-OF-NETWORK  
Individual Annual Calendar Year Deductible $50 $50 NOT COVERED
Family Annual Calendar Year Deductible $150 $150  
Maximum (the sum of all Network and Out-of-Network benefits will not exceed Maximum Benefits) $2000 per person per Calendar Year $2000 per person per Calendar Year  
Annual deductible applies to preventive and diagnostic services No (In Network)
No (Out-of-Network)
Solstice BenefitsBooster Included (Increasing Calendar Year Maximum Benefit) Yes
Preventive Waiver Saver Included (P&D Services Do Not Accumulate Towards Annual Maximum) No
Orthodontic eligibility requirement N/A
COVERED SERVICES NETWORK PLAN PAYS* OUT-OF-NETWORK
PLAN PAYS**		 BENEFIT GUIDELINES
PREVENTIVE & DIAGNOSTIC SERVICES
Periodic Oral Evaluation 100% 100% Limited to two (2) times per consecutive twelve (12) months.
Routine Radiographs 100% 100% Bitewings: Limited to one (1) series of films per consecutive twelve (12) months.
Non-Routine - Complete Series Radiographs 100% 100% Complete Series/Panorex: Limited to one (1) time per consecutive thirty-six (36) months.
Prophylaxis (Cleanings) 100% 100% Limited to (2) prophylaxis in any twelve (12) consecutive months, to a maximum of (2) total prophylaxis and periodontal maintenance procedures in any twelve (12) consecutive months.
Fluoride Treatment 100% 100% Limited to Covered Persons under the age of sixteen (16) years, and to one (1) time per consecutive twelve (12) months.
Sealants 100% 100% Limited to Covered Persons under the age of sixteen (16) years, and to one (1) time per first or second unrestored permanent molar every consecutive thirty-six (36) months.
Space Maintainers 100% 100% Limited to Covered Persons under the age of sixteen (16) years, one (1) time per consecutive sixty (60) months. Benefit includes all adjustments within six (6) months of installation.
Palliative Treatment 100% 100% Covered as a separate benefit only if no other service, other than exam and radiographs, were done during the visit
BASIC SERVICES
Restorations (Amalgam or Composite) 80% 80% Multiple restorations on one (1) surface will be treated as a single filling.
Simple Extractions 80% 80% Limited to one (1) time per tooth per lifetime.
Oral Surgery (includes surgical extractions) 50% 50% Extractions: Limited to one (1) time per tooth per lifetime.
Periodontics 50% 50% Periodontal Surgery: Limited to one (1) quadrant or site per consecutive thirty-six (36) months per surgical area. Scaling and Root Planing: Limited to one (1) time per quadrant per consecutive twenty-four (24) months.
Periodontal Maintenance: Limited to two (2) periodontal maintenance in any twelve (12) consecutive months, to a maximum of two (2) total prophylaxis and periodontal maintenance procedures in any twelve(12) consecutive months.
Endodontics 50% 50%  
Anesthetics 80% 80% General Anesthesia: When clinically necessary.
Adjunctive Services 80% 80%  
MAJOR SERVICES (12 Month Waiting Period)
Inlays/Onlays/Crowns 50% 50% Limited to one (1) time per tooth per consecutive sixty (60) months.
Dentures and other Removable Prosthetics 50% 50% Full Denture/Partial Denture: Limited to one (1) per consecutive sixty (60) months. No additional allowances for precision or semi precision attachments.
Fixed Partial Dentures (Bridges) 50% 50% Bridges: Limited to one (1) time per tooth per consecutive sixty (60) months
ORTHODONTIC SERVICES
Diagnose or correct misalignment of the teeth or bite Not Covered Not Covered Not Covered
       
*The network percentage of benefits is based on the discounted fees negotiated with the provider.
**Out of-Network benefits are based on the participating provider contracted fees.
The above Summary of Benefits is for informational purposes only and is not an offer of coverage. Please note that the above table provides only a brief, general description of coverage and does not constitute a contract. For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of Coverage or contact your benefits administrator. If differences exist between this Summary of Benefits your Certificate of Coverage/benefits administrator, the Certificate of Coverage/benefits administrator will govern. All terms and conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan design features.