BROUGHT TO YOU BY:
North Carolina Medical Society
Sentinel Benefits Consulting

BROUGHT TO YOU BY:
North Carolina Medical Society
Sentinel Benefits Consulting

Dental Plan Offerings

PLAN A
PLAN B
PLAN C
PLAN D
PLAN E

Plan A

  • No Annual Deductible
  • Annual Maximum Benefit: $1,000
  • In-Network: PDP Fee Schedule
  • Out-of-Network: 90% of Reasonable & Customary
  • Alternate Benefits (based on plan benefit): Member is responsible for charges exceeding benefit
Benefit Summary

MONTHLY RATES

Employee: $34.10
Employee Plus 1: $65.22
Employee Plus 2: $84.15
Employee Plus Family: $114.16

Preventive Services
Oral Exams / Prophylaxis Cleanings
1 in 6 months
Bitewing X-Rays (Adult / Child)
1 in 12 months / 1 in 6 months
Topical Flouride Application (Child to age 14)
1 in 12 months

100% covered. No Waiting Period.
Basic Services
Space Maintainers (Child to age 14)
No Limit
Sealants (Child to age 14)
1 in a lifetime
Full Mouth X-Rays
1 in 60 months
Periodontal Maintenance
4 in 1 year (includes 2 cleanings)
Amalgam / Composite Fillings
1 in 24 months (anterior teeth only)

80% covered. No Waiting Period.
Major Services
Crowns/Inlays/Onlays
1 per tooth in 10 years
Prefabricated Crowns Impant Services
1 per tooth in 60 months
Endodontics Root Canal
1 per tooth in 24 months
Periodontal Surgery
1 in 36 months per quadrant
Periodontal Scaling & Root Planing
1 in 24 months per quadrant
Bridges/Dentures
1 in 10 years
Consultations
2 in 12 months

50% covered. 12-Month Waiting Period.

Plan B

  • No Annual Deductible
  • Annual Maximum Benefit (per individual): $1,250
  • In-Network: PDP Fee Schedule
  • Out-of-Network: 90% of Reasonable & Customary
  • Alternate Benefits (based on plan benefit): Member is responsible for charges exceeding benefit
Benefit Summary

MONTHLY RATES

Employee: $46.74
Employee Plus 1: $89.37
Employee Plus 2: $115.31
Employee Plus Family: $156.37

Preventive Services
Oral Exams / Prophylaxis Cleanings
1 in 6 months
Bitewing X-Rays (Adult / Child)
2 in 12 months / 1 in 6 months
Topical Flouride Application (Child to age 14)
1 in 12 months
Space Maintainers (Child to age 14)
No Limit
Sealants (Child to age 14)
1 per molar per lifetime

100% covered. No Waiting Period.
Basic Services
Full Mouth X-Rays
1 in 60 months
Amalgam / Composite Fillings
1 in 24 months (anterior teeth only)
Periodontal Maintenance
4 in 1 year (includes 2 cleanings)
Endodontics Root Canal
1 per tooth in 24 months

80% covered. No Waiting Period.
Major Services
Crowns/Inlays/Onlays
1 per tooth in 10 years
Prefabricated Crowns Impant Services
1 per tooth in 60 months
Periodontal Surgery
1 in 36 months per quadrant
Periodontal Scaling & Root Planing
1 in 24 months per quadrant
Bridges/Dentures
1 in 10 years
Repairs
No Limit
Consultations
2 in 12 months

50% covered. 12-Month Waiting Period.

Plan B - With Orthodontia

  • 50% Covered
  • Lifetime Maximum: $1,000
  • 12-Month Waiting Period
  • In-Network Individual Out-of-Pocket (1 child): $350
  • In-Network Family Out-of-Pocket ( 2 of more children): $700
  • Orthodontia applies to children only to age 19
Benefit Summary

MONTHLY RATES

Employee: $46.74
Employee Plus 1: $89.37
Employee Plus 2: $123.51
Employee Plus Family: $168.36

Orthodontia must be medically necessary and must begin while coverage is in force. All dental procedures in connection with Orthodontic treatment are payable as Orthodontia. Benefits for initial placement will not exceed 20% of the lifetime maximum. Periodic follow-up visits will be paid on a monthly basis during the course of treatment. Initial placement/follow-up visits/procedures are subject to Orthodontia coinsurance level and lifetime maximum. Orthodontic benefits end at cancellation of coverage.

Plan C

  • No Annual Deductible for Individual and Family
  • Annual Maximum Benefit (per individual): $1,500
  • In-Network: PDP Fee Schedule
  • Out-of-Network: 90% of Reasonable & Customary
  • Alternate Benefits (based on plan benefit): Member is responsible for charges exceeding benefit
Benefit Summary

MONTHLY RATES

Employee: $50.34
Employee Plus 1: $96.22
Employee Plus 2: $124.20
Employee Plus Family: $168.46

Preventive Services
Oral Exams / Prophylaxis Cleanings
1 in 6 months
Bitewing X-Rays (Adult / Child)
2 in 12 months / 1 in 6 months
Topical Flouride Application (Child to age 14)
1 in 12 months
Space Maintainers (Child to age 14)
No Limit
Sealants (Child to age 14)
1 per molar per lifetime
Full Mouth X-Rays
1 in 60 months

100% covered. No Waiting Period.
Basic Services
Endodontics Root Canal
1 per tooth in 24 months
Amalgam / Composite Fillings
1 in 24 months (anterior teeth only)
Periodontal Maintenance
4 in 1 year (includes 2 cleanings)
Periodontal Surgery
1 in 36 months per quadrant
Periodontal Scaling & Root Planing
1 in 24 months per quadrant

80% covered. No Waiting Period.
Major Services
Crowns/Inlays/Onlays
1 per tooth in 10 years
Prefabricated Crowns Impant Services
1 per tooth in 60 months
Bridges/Dentures
1 in 10 years
Repairs
No Limit
Consultations
2 in 12 months

50% covered. 12-Month Waiting Period.

Plan C - With Orthodontia

  • 50% Covered
  • Lifetime Maximum: $1,000
  • 12-Month Waiting Period
  • In-Network Individual Out-of-Pocket (1 child): $350
  • In-Network Family Out-of-Pocket ( 2 of more children): $700
  • Orthodontia applies to children only to age 19
Benefit Summary

MONTHLY RATES

Employee: $50.34
Employee Plus 1: $96.22
Employee Plus 2: $133.05
Employee Plus Family: $181.49

Orthodontia must be medically necessary and must begin while coverage is in force. All dental procedures in connection with Orthodontic treatment are payable as Orthodontia. Benefits for initial placement will not exceed 20% of the lifetime maximum. Periodic follow-up visits will be paid on a monthly basis during the course of treatment. Initial placement/follow-up visits/procedures are subject to Orthodontia coinsurance level and lifetime maximum. Orthodontic benefits end at cancellation of coverage.

Plan D

  • In-Network Individual Deductible: $50
  • In-Network Family Deductible: $150
  • Annual Maximum Benefit (per individual): $1,500
  • In-Network: PDP Fee Schedule
  • Out-of-Network: 90% of Reasonable & Customary
  • Alternate Benefits (based on plan benefit): Member is responsible for charges exceeding benefit
Benefit Summary

MONTHLY RATES

Employee: $53.05
Employee Plus 1: $101.44
Employee Plus 2: $130.87
Employee Plus Family: $177.51

Preventive Services
Oral Exams / Prophylaxis Cleanings
1 in 6 months
Bitewing X-Rays (Adult / Child)
2 in 12 months / 1 in 6 months
Topical Flouride Application (Child to age 14)
1 in 12 months
Space Maintainers (Child to age 14)
No Limit
Sealants (Child to age 14)
1 per molar per lifetime
Full Mouth X-Rays
1 in 60 months

100% covered. No Waiting Period.
Basic Services
Endodontics Root Canal
1 per tooth in 24 months
Amalgam / Composite Fillings
1 in 24 months (anterior teeth only)
Periodontal Maintenance
4 in 1 year (includes 2 cleanings)
Prefabricated Crowns Implant Services
1 per tooth in 60 months
Consultations
2 in 12 months

80% covered. No Waiting Period.
Major Services
Crowns/Inlays/Onlays
1 per tooth in 10 years
Periodontal Surgery
1 in 36 months per quadrant
Bridges/Dentures
1 in 10 years
Repairs
No Limit
Periodontal Scaling & Root Planing
1 in 24 months per quadrant
Implant Services
1 service per tooth in 60 months / 1 repair per 60 months

50% covered. 12-Month Waiting Period.

Plan D - With Orthodontia

  • 50% Covered
  • Lifetime Maximum: $1,500
  • 12-Month Waiting Period
  • In-Network Individual Out-of-Pocket (1 child): $350
  • In-Network Family Out-of-Pocket ( 2 of more children): $700
  • Orthodontia applies to children only to age 19
Benefit Summary

MONTHLY RATES

Employee: $53.05
Employee Plus 1: $101.44
Employee Plus 2: $144.21
Employee Plus Family: $197.14

Orthodontia must be medically necessary and must begin while coverage is in force. All dental procedures in connection with Orthodontic treatment are payable as Orthodontia. Benefits for initial placement will not exceed 20% of the lifetime maximum. Periodic follow-up visits will be paid on a monthly basis during the course of treatment. Initial placement/follow-up visits/procedures are subject to Orthodontia coinsurance level and lifetime maximum. Orthodontic benefits end at cancellation of coverage.

Plan E

  • In-Network Individual Deductible: $50
  • In-Network Family Deductible: $150
  • Annual Maximum Benefit (per individual): $5,000
  • In-Network: PDP Fee Schedule
  • Out-of-Network: 90% of Reasonable & Customary
  • Alternate Benefits (based on plan benefit): Member is responsible for charges exceeding benefit
Benefit Summary

MONTHLY RATES

Employee: $55.73
Employee Plus 1: $106.53
Employee Plus 2: $137.24
Employee Plus Family: $186.19

Preventive Services
Oral Exams / Prophylaxis Cleanings
1 in 6 months
Bitewing X-Rays (Adult / Child)
2 in 12 months / 1 in 6 months
Topical Flouride Application (Child to age 14)
1 in 12 months
Space Maintainers (Child to age 14)
No Limit
Sealants (Child to age 14)
1 per molar per lifetime
Full Mouth X-Rays
1 in 60 months

100% covered. No Waiting Period.
Basic Services
Endodontics Root Canal
1 per tooth in 24 months
Amalgam / Composite Fillings
1 in 24 months (anterior teeth only)
Periodontal Maintenance
4 in 1 year (includes 2 cleanings)
Prefabricated Crowns Implant Services
1 per tooth in 60 months
Consultations
2 in 12 months

80% covered. No Waiting Period.
Major Services
Crowns/Inlays/Onlays
1 per tooth in 10 years
Periodontal Surgery
1 in 36 months per quadrant
Bridges/Dentures
1 in 10 years
Repairs
No Limit
Periodontal Scaling & Root Planing
1 in 24 months per quadrant
Implant Services
1 service per tooth in 60 months / 1 repair per 60 months

50% covered. 12-Month Waiting Period.

Plan E - With Orthodontia

  • 50% Covered
  • Lifetime Maximum: $1,500
  • 12-Month Waiting Period
  • In-Network Individual Out-of-Pocket (1 child): $350
  • In-Network Family Out-of-Pocket ( 2 of more children): $700
  • Orthodontia applies to children only to age 19
Benefit Summary

MONTHLY RATES

Employee: $55.73
Employee Plus 1: $106.53
Employee Plus 2: $1351.25
Employee Plus Family: $206.77

Orthodontia must be medically necessary and must begin while coverage is in force. All dental procedures in connection with Orthodontic treatment are payable as Orthodontia. Benefits for initial placement will not exceed 20% of the lifetime maximum. Periodic follow-up visits will be paid on a monthly basis during the course of treatment. Initial placement/follow-up visits/procedures are subject to Orthodontia coinsurance level and lifetime maximum. Orthodontic benefits end at cancellation of coverage.

  • Privacy Policy
  • Terms & Conditions
  • © 2024 NCMS Employee Benefit Plan. All rights reserved.