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Douglas County - WI DEN WISC Open Access Choice SI HP Dental - Open Access 1-1-2020 DEN WISC Open Access Choice SI The following is an overview of your HealthPartners coverage. For exact coverage terms and conditions, consult your plan materials. Plan highlights In-network Out-of-Network Partial listing of covered services Care from a network provider Care from an out-of-network provider * Dental Plan Parameters Annual Maximums & Deductibles are combined across all tiers - Annual maximum $1,000 per calendar year $1,000 per calendar year - Individual Deductible (Applies to Basic Care, Special Care & Prosthetics) $50 $50 - Family Deductible (Applies to Basic Care, Special Care & Prosthetics) $150 $150 Implant maximum included in annual maximum $500 $500 Preventive and Diagnostic Care - Teeth cleaning, exams, dental x-rays and fluoride treatments 100% 100% - Sealants 100% 100% Basic Care Basic Care I - Fillings (amalgam and anterior composite) 80% 80% - Posterior composite (white fillings) 50% 50% - Simple extractions 80% 80% - Non-surgical periodontics 80% 80% - Endodontics (root canal therapy) 50% 50% Basic Care II - Surgical periodontics 50% 50% - Complex oral surgery 50% 50% Special Care - Restorative crowns & onlays 50% 50% Prosthetics - Bridges, dentures & partial dentures 50% 50% - Dental implants 50% 50% Orthodontic Services Orthodontic lifetime maximums are combined in and out-of- network - Orthodontic care for all ages NO COVERAGE NO COVERAGE * If your out-of-network dentist charges more than the maximum allowable amount, you may be responsible for the difference. Emergency Care: Refer to the Group Dental Member Contract for coverage of emergency dental services Diabetes and Pregnancy: Additional periodontal services (exams, cleanings, scaling and root planing, and debridement) for our members who are diabetic and/or pregnant are covered at 100% in-network. Deductibles, annual maximums, and frequency limitations will be waived on these specific services for members referred into the program by a HealthPartners network dentist. Benefit Limitations