SMILE. WE'VE GOT YOU COVERED.

MEMBER DENTAL AND VISION BENEFITS.

Which plan is right for you?

Below you can compare monthly rates and coverage under the Discount, Select, Choice PPO and Elite ePPO options. For more details, you can view a Complete List of Benefits for each plan at the bottom of the chart, including pediatric dental plans. The "Percentages" tab below shows how much each of the plans cover for each of the listed procedures. Click the "Copayments" tab to see a comparison that shows how much you would pay (in dollar amounts), for these procedures for each of these plans.

Monthly Rates    Discount Select Plan Premium Choice PPO Basic
Benefit Features Plan Offers Plan Offers Plan Offers
Office Visit Charge $15 $10 None
Deductibles None None $50 per insured person
($150 family max)
Annual Maximum Limits  None None $1,000 per insured person
Lifetime Maximum Limits for Orthodontics None None N/A
Waiting Periods None None None
Claims Forms None None Yes
Must Use a Network Dentist Yes Yes No
Benefit Coverage Examples
(See complete list of benefits for all procedures)  
We Cover1 We Cover1 We Cover
(Yr. 1)
We Cover
(Yr. 2)
We Cover
(Yr. 3)
 I.  Diagnostic/Preventive Care (45%-100%) (100%) (100%) (100%) (100%)
Oral Exam 100% 100% 100% 100% 100%
Bitewing X-Rays  45% 100% 100% 100% 100%
Cleaning for Adults 100% (1 per year) 100% 100% 100% 100%
Cleaning for Children 100% (1 per year) 100% 100% 100% 100%
Topical Fluoride - For Children 100% 100% 100% 100% 100%
 II. Basic Care (45%-50%) (70%-80%) (50%) (60%) (80%)
Full Mouth X-Rays 50% 80% 50% 60% 80%
Silver Filling (2 Surfaces) 45% 70% 50% 60% 80%
Composite Filling (2 Surfaces) 50%   70%   50% 60%   80%  
Simple (Routine) Extraction   45%   70%   50% 60%     80%    
 III. Major Restorative Care (45%-60%) (55%-70%) (15%) (25%) (50%)
Periodontal Scaling/Root Planing 50% 55% 15% 25% 50%
Perio Surgery (Gingivectomy/Gingivoplasty)  50% 55% 15% 25% 50%
Root Canal (Anterior Tooth) 60% 70% 15% 25% 50%
Crown (Porcelain Fused to Metal) 45% 60% 15% 25% 50%
Denture (Complete Upper/Lower) 45% 70% 15% 25% 50%
 IV. Orthodontics
Children 45% 45% 0% 0% 0%
Adults 45% 45% 0% 0% 0%
Complete List of Benefits    Discount

Adult
Select Plan Premium

Pediatric
Select Plan Premium Kids

Adult
Choice PPO Basic


Pediatric
Choice PPO Premium Kids

 

Additional Plans 


 
Choice PPO Plus Choice PPO PremiumElite ePPO Premium
Benefit FeaturesPlan OffersPlan Offers  Plan Offers
Office Visit ChargeNoneNoneNone
Deductibles$50 per insured person$50 per insured person  $25 per insured person
Annual Maximum Limits $750 per insured person  $1,500 per insured person  $1,500 per insured person
Lifetime Maximum Limits for OrthodonticsNANANA
Waiting PeriodsNone0/6/12None
Claims FormsYesYesYes
Must Use a Network DentistNoNoYes
Benefit Coverage Examples
(See complete list of benefits for all procedures)  
We Cover
(In-Network | Out-of-Network)
We Cover
(In-Network | Out-of-Network) 
We Cover1
 I.  Preventive/Diagnostic Services(100% | 90%)(100%)  (100%)
Oral Examination100% | 90%100% | 90%   100%
Bitewing X-Rays 100% | 90%    100% | 90%  100%
Cleaning for Adults100% | 90%  100% | 90%  100%
Cleaning for Children100% | 90%  100% | 90%  100%
Topical Fluoride - For Children100% | 90%  100% | 90%  100%
 II. Basic Restorative Services(50% | 40%)(80% | 70%)  (70%-80%)
Full Mouth X-Rays100% | 90%  (Class I)100% | 90%  (Class I)  100% (Class I)
Silver Filling (Two Surfaces)50% | 40%  80% | 70%  85%
Composite Filling (Two Surfaces)50% | 40%  80% | 70%85%
 III. Major Restorative Services(0% | 0%)(50% | 40%)  (45%-75%)
Simple (Routine) Extraction50% | 40%  (Class II)50% | 40%  (Class II)    60%
Periodontal Scaling/Root Planing50% | 40%  (Class II)50% | 40% 70%
Perio Surgery (Gingivectomy/Gingivoplasty) 0% | 0%  50% | 40% 60%
Root Canal (Molar)0% | 0%  50% | 40% 50%
Crown (Porcelain Fused to Metal)0% | 0%  50% | 40% 60%
Denture (Complete Upper/Lower)0% | 0%  50% | 40% 75%
 IV. Orthodontics
Children0% | 0%  0% | 0%  0%
Adults0% | 0%  0% | 0%  0%
Complete List of Benefits   

Adult
Choice PPO Plus

Pediatric
Choice PPO Premium Kids

Adult
Choice PPO Premium

Pediatric
Choice PPO Premium Kids

Adult

Elite ePPO Premium

Pediatric
Choice PPO Premium Kids

1 Approximate percentage of coverage based on the Context4Healthcare's 80th percentile. Based on zip 223. A specific fee schedule applies and will be mailed with your membership card. Please see the Summary of Member Fees (Discount) or the Description of Member Copayments (Select Plan and Elite ePPO) inside the brochure for a sample of member fees. To view copay schedules for the pediatric plans, go to DominionNational.com/pediatric.
2 Year 1 benefits apply during the subscriber's first 12 months of continuous coverage. Year 2 benefits apply during the subscriber's second 12 months of continuous coverage and Year 3 benefits apply during the subscriber's third 12 months of continuous coverage.

 

Which plan is right for you?

Below you can compare monthly rates and coverage under the Discount, Select, Choice PPO and Elite ePPO options. For more details, you can view a Complete List of Benefits for each plan at the bottom of the chart, including pediatric dental plans. The "Copayments" tab below shows how much you would pay (in dollar amounts), for these procedures for each of these plans. Click the "Percentages" tab to see a comparison that shows how much each of the plans cover for each of the listed procedures.

  Discount Select Plan Premium Choice PPO Basic
Benefit Features Plan Offers Plan Offers Plan Offers
Office Visit Charge $15 $10 None
Deductibles None None $50 per insured person
($150 family max)
Annual Maximum Limits  None None $1,000 per insured person
Lifetime Maximum Limits for Orthodontics None None N/A
Waiting Periods None None None
Claims Forms None None Yes
Must Use a Network Dentist Yes Yes No
Benefit Coverage Examples
(See complete list of benefits for all procedures)  
Average Cost
Without a Plan1
You Pay You Pay You Pay2
(Year 1)
You Pay2
(Year 2)
You Pay2
(Year 3)
 I.  Diagnostic/Preventive Care
Oral Exam $86 $0 $0 $0 $0 $0
Bitewing X-Rays  $40 $22 $0 $0 $0 $0
Cleaning for Adults $90 $0
(1 per year)
$0 $0 $0 $0
Cleaning for Children $65 $0
(1 per year)
$0 $0 $0 $0
Topical Fluoride - For Children $42 $0 $0 $0 $0 $0
 II. Basic Care
Full Mouth X-Rays $130 $66 $26 $65 $52 $26
Silver Filling (Two Surfaces) $151 $81 $46 $76 $60 $30
Composite Filling (Two Surfaces) $190 $97 $76 $95 $76 $38
Simple (Routine) Extraction $139 $81 $63 $70 $56 $28
 III. Major Restorative Care
Periodontal Scaling/Root Planing $247 $126 $105 $210 $185 $124
Perio Surgery (Gingivectomy/Gingivoplasty)  $676 $338 $265 $575 $507 $338
Root Canal (Molar Tooth) $897 $526 $488 $762 $673 $449
Crown (Porcelain Fused to Metal) $1,210 $644 $495 $1,028 $908 $605
Denture (Complete Upper/Lower) $1,493 $778 $664 $1,269 $1,120 $747
 IV. Orthodontics
Children $6,244 $3,422 $3,422 Not Covered Not Covered Not Covered
Adults $6,244 $3,658 $3,658 Not Covered Not Covered Not Covered
Complete List of Benefits      Discount  Adult
Select Plan Premium
 

 

Pediatric
Select Plan Premium Kids

 

Adult
Choice PPO Basic

Pediatric
Choice PPO Premium Kids

 

 

 

 

Additional Plans

 Choice PPO PlusChoice PPO PremiumElite ePPO Premium
Benefit FeaturesPlan OffersPlan OffersPlan Offers
Office Visit ChargeNone  None  None
Deductibles$50 per insured person$50 per insured person$25 per insured person
Annual Maximum Limits $750 per insured person $1,500 per insured person  $1,500 per insured person
Lifetime Maximum Limits for OrthodonticsNANANA
Waiting PeriodsNone0/6/12None
Claims FormsYesYesYes
Must Use a Network DentistNoNoYes
Benefit Coverage Examples
(See complete list of benefits for all procedures)  
Average Cost 
Without a Plan1
You Pay2
(In-Network 
Out-of-Network) 
 
You Pay2
(In-Network | Out-of-Network) 
You Pay
 
 I.  Preventive/Diagnostic Services
Oral Examination$86$0 | $0 $0 | $0$0
Bitewing X-Rays $40$0 | $0    $0 | $0$0
Cleaning for Adults$90$0 | $0   $0 | $0$0
Cleaning for Children$65$0 | $0   $0 | $0$0
Topical Fluoride - For Children$42$0 | $0   $0 | $0$0
 II. Basic Restorative Services
Full Mouth X-Rays$130$0 | $0     $0 | $0$0
Silver Filling (Two Surfaces)$151$75 | $90 $75 | $90$30
Composite Filling (Two Surfaces)$190$95 | $114 $95 | $114$42
 III. Major Restorative Services
Simple (Routine) Extraction$139$69 | $83 $69 | $83$50
Periodontal Scaling/Root Planing$247$123 | $148 $123 | $148$97
Perio Surgery (Gingivectomy/Gingivoplasty) $676Not Covered      $338 | $405$198
Root Canal (Molar)$897Not Covered     $448 | $538$780
Crown (Porcelain Fused to Metal)$1,210Not Covered   $605 | $1,026$520
Denture (Complete Upper/Lower)$1,493Not Covered   $747 | $896$560
 IV. Orthodontics
Children$6,244Not Covered  Not CoveredNot Covered
Adults$6,244Not Covered  Not CoveredNot Covered
Complete List of Benefits   

Adult
Choice PPO Plus

Pediatric
Choice PPO Premium Kids

Adult
Choice PPO Premium

Pediatric
Choice PPO Premium Kids

Adult

Elite ePPO Premium

Pediatric
Choice PPO Premium Kids

1 Average costs based on the Captiva Context Fee Schedule's 80th percentile for zip codes beginning with 223.
2 Payment amounts are estimates based on the percentage covered in-network using the Captiva Context Fee Schedule's 80th percentile.