To Find a Dental Provider…

Contact Pequot Plus Customer Service at 1-888-779-6872 for the most current list of which dental providers participate in the MPTN dental network.

How the Plan Works

With the MPTN Dental Plan, you have coverage regardless of which licensed dental care provider you use. However, you generally pay less when you receive care from an in-network provider. If you receive care from an out-of-network provider, you will pay your deductible, your coinsurance and any portion of the fee in excess of the plan allowance, which is the preset fee on which plan benefits are based.

In addition, if you receive any dental service or care — either in- or out-of-network — that is not listed on the schedule below, you will pay the provider in full. The fees are not eligible for reimbursement and do not count against your deductible. For more information about specific dental benefits, contact Pequot Plus Customer Service before you receive treatment.

The benefits you receive depend on the type of care you receive, as shown in the following table.

About the Plan Allowance

The percentages shown in the table are percentages of the plan allowance — preset fees on which plan benefits are based.

• Allowed amounts will not exceed contracted rates.
• If you use an out-of-network provider who charges more than the plan allowance, you are responsible for paying 100% of the difference between the plan allowance and the provider’s fee, in addition to the portion of the plan allowance that the plan does not pay.

Deductible

The deductible is the amount you and each covered family member must pay each plan year for out-of-network covered dental care before the plan begins to pay certain benefits. There is no deductible for in-network care or preventive dental services — whether in- or out-of-network.

A $100 individual deductible applies separately to you and to each of your covered family members, up to a total of $300 maximum per family. A new deductible applies each plan year, except for orthodontic services — the $50 orthodontic deductible is per case.

Alternate Benefit

If more than one type of dental service can be used to treat a dental condition, we have the right to base benefits on the least expensive service which is within the range of professionally accepted standards of dental practice. In the case of bilateral, multiple adjacent missing teeth, the benefit will be based on a removable partial denture.

Coinsurance

Once you meet the deductible (if applicable), the plan pays a percentage (100%, 80% or 50%, depending on the dental service) of the plan allowance for most covered expenses. The remaining percentage you pay is called your coinsurance.

Maximums

• Annual maximum — The maximum reimbursement you can receive each plan year for covered dental service (other than orthodontia) is $1,500 per participant. Once you reach the maximum, you pay the full cost for all services for the remainder of the plan year.
• Lifetime maximum — There is a separate lifetime limit of $1,500 per covered child, through age 18, for orthodontic services.

In-Network Advantages

Choosing a network provider for dental care offers the following advantages:

• No deductible
• Fees for services are agreed upon in advance, and that savings is  passed on to you in the form of reduced rates
• Allowed amounts will not exceed the provider’s contracted rates
• MPTN will pay the provider directly, so you only pay your share of the cost

Other Coverage

The MPTN Dental Plan has a coordination of benefits feature to prevent duplication of payments when you or your family members are covered by another group dental plan.

Preventive Services

The plan pays 100% of the plan allowance, with no deductible, for:

• one initial exam per office, per person,
• routine exams (up to twice a year, including the initial exam),
• comprehensive periodontal exam (once every 12 months),
• bitewing X-rays (once every 12 months),
• full mouth series X-rays (once every 36 months),
• Panorex (once every 36 months)
• cleanings (once every six months),
• fluoride treatments (once every six months, through age 18),
• space maintainers (through age 13), and
• sealant for first and second permanent molars (through age 15, one time per tooth, with no decay).

*Please note: Multiple X-rays taken on the same day by the same provider may be combined to an alternate benefit. A Panorex and full mouth series will not be payable to the same provider within a 36-month period.

X-Ray Requirements

To receive benefits from the plan, X-rays are required for the following procedures:

• Root canals — pre-op and post-op
• Crown/bridge — pre-op
• Periodontics — pre-op
• Oral surgery — pre-op
• Anterior composite restorations that involve four or more surfaces or that involve incisal angle.

X-rays and/or documentation may be requested for any treatment in order to provide clarification for a claim.

Basic Services

The plan pays 80% of the plan allowance, after a deductible (if out-of-network), for:

• fillings,
• simple extractions,
• oral surgery, including removal of impacted teeth,
• anesthetics (in conjunction with oral surgery),
• treatment of the gums (periodontics), and
• root canal therapy and other endodontic care.

Major Services

The plan pays 50% of the plan allowance, after a deductible (if out-of-network), for:

• caps and crowns,
• bridges and dentures (prosthodontics),
• replacement of caps, crowns, bridges and dentures (once every five years), and
• implants (once every five years), to replace extracted permanent teeth

Orthodontic Services

The plan pays 50% of the plan allowance, up to a lifetime maximum benefit of $1,500, after a deductible (if out-of-network), for orthodontic services for covered children through age 18.