SMILE. WE'VE GOT YOU COVERED.

MEMBER DENTAL AND VISION BENEFITS.

Which plan is right for you?

Below you can compare coverage for Dominion's plans. For more details, you can view the plan documents at the bottom of the chart. The "Percentages" tab below shows how much each of the plans cover for each of the listed procedures. Click the "Copayments" tab to see an in-network comparison that shows how much you would pay for these procedures for each of these plans. Rates for the plans are based on your county and state. To view information regarding the vision plan, click here. For more information, please contact Member Services at 877.681.3879.

Benefit Features Discount Program1 Choice PPO Basic
Office Visit $15 N/A
Deductibles None $50 per member (max per family $150)3
Annual Maximums None $1,000 per insured person
Waiting Periods None None
Receive Care From Discount Network Dentist Choice PPO network dentist or any licensed dentist
States Available DC, DE, MD, NJ, PA, VA All
Procedures and Covered Services   Year 12 
In/Out Network
Year 22 
In/Out Network
Year 32 
In/Out Network
I.  Diagnostic & Preventive        
Comprehensive Oral Exam 100% 100% | 90% 100% | 90% 100% | 90%
Bitewing X-Rays (4 Films) 45% 100% | 90% 100% | 90% 100% | 90%
Teeth Cleaning (Adult) 100% (1 per year) 100% | 90% 100% | 90% 100% | 90%
Topical Fluoride for Children 100% 100% | 90% 100% | 90% 100% | 90%
II. Basic Restorative        
Full and panoramic X-rays 45% 100% | 90% 100% | 90% 100% | 90%
Amalgam filling (silver) 50% 50% | 30% 60% | 50% 80% | 70%
Composite filling (white) 50% 50% | 30% 60% | 50% 80% | 70%
Extraction, erupted tooth 50% 50% | 30% 60% | 50% 80% | 70%
III. Major Restorative        
Crown (Porcelain/Metal) 45% 15% | 10% 25% | 20% 50% | 40%
Bridges 45% 15% | 10% 25% | 20% 50% | 40%
Complete Denture 45% 15% | 10% 25% | 20% 50% | 40%
Relining of dentures 35% 15% | 10% 25% | 20% 50% | 40%
Periodontics (root planing and therapy) 50% 15% | 10% 25% | 20% 50% | 40%
Endodontics (root canals) 60% 15% | 10% 25% | 20% 50% | 40% 
Oral Surgery (extraction of impacted teeth) 40% 15% | 10% 25% | 20% 50% | 40%
IV. Orthodontics
Adults and Children 48% 0% | 0% 0% | 0% 0% | 0%
Plan Document Discount Program

Choice PPO Basic

 

Additional Plans

Benefit FeaturesSelect Plan Premium1Choice PPO PremiumElite ePPO Premium1
Office Visit$10NoneNone
DeductiblesNone$50 per member (max per family $150)4 $25 per member (max per member $75)4
Annual MaximumsNone$1,500 per insured person$1,500 per insured person
Waiting PeriodsNoneYes5None
Receive Care FromSelect Plan Network DentistChoice PPO network dentist or any licensed dentistElite ePPO Network Dentist
States AvailableDC, DE, MD, NJ, PA, VAAllDC, MD, PA, VA
Procedures and Covered Services In/Out Network 
I.  Diagnostic & Preventive   
Comprehensive Oral Exam100%100% | 90%   100%
Bitewing X-Rays (4 Films)100%100% | 90%  100%
Teeth Cleaning (Adult)100%100% | 90%  100%
Topical Fluoride for Children100%100% | 90%100%
II. Basic Restorative   
Full and panoramic X-rays80%100% | 90%100%
Amalgam filling (silver)80%80% | 70%85%
Composite filling (white)70%80% | 70%85%
Extraction, erupted tooth70%80% | 70%  75%
III. Major Restorative    
Crown (Porcelain/Metal)60%50% | 40%   60%
Bridges60%50% | 40%    60%
Complete Denture70%50% | 40%    75%
Relining of dentures60%50% | 40%   70%
Periodontics (root planing and therapy)55%50% | 40%  60%
Endodontics (root canals)70%50% | 40%50%
Oral surgery (extraction of impacted teeth)55%50% | 40%  60%
IV. Orthodontics
Adults and Children48%0% | 0%   0%
Plan Document   Select Plan Premium

Choice PPO Premium

Elite ePPO Premium

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.
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. Year 3 benefits apply during the subscriber's third 12 months of continuous coverage.
3 Deductibles apply to all services.
4 Deductibles apply to basic care and major restorative care.
5 There are no waiting periods for diagnostic and preventive care or basic care. To be eligible for major restorative care, you must have completed 6 (six) months of continuous coverage. Waiting period credit will be given for the length of time an insured was covered under each benefit classification under the current employer's prior dental coverage.

Which plan is right for you?

Below you can compare in-network coverage for Dominion's plans. For more details, you can view the plan documents at the bottom of the chart. The "Copayments" tab below shows how much you would pay 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. Rates for the plans are based on your county and state. To view information regarding the vision plan, click here. For more information, please contact Member Services at 877.681.3879.

Benefit Features Discount Program Choice PPO Basic
Office Visit $15 N/A
Deductibles None $50 per member (max per family $150)3
Annual Maximums None $1,000 per insured person
Waiting Periods None None
Receive Care From Discount Network Dentist Choice PPO network dentist or any licensed dentist
States Available DC, DE, MD, NJ, PA, VA All
Procedures and Covered Services Avg. Cost Without Plan1  You Pay You Pay
Year 11,2
You Pay
Year 21,2
You Pay
Year 31,2
I.  Diagnostic & Preventive
Comprehensive Oral Exam $85 $0 $0 $0 $0
Bitewing X-Rays (4 Films) $74 $31 $0 $0 $0
Teeth Cleaning (Adult) $102 $0 (1 per year) $0 $0 $0
Topical Fluoride for Children $41 $0 $0 $0 $0
II. Basic Restorative
Filling (3-Surface/Silver) $217 $107 $109 $87 $43
Complete Series X-Rays $161 $66 $0 $0 $0
III. Major Restorative
Crown (Porcelain/Metal) $1,299 $677 $1,104 $974 $650
Complete Denture $1,785 $895 $1,517 $1,339 $893
Root Canal (Anterior Tooth) $747 $413 $635 $560 $374
Perio Scaling/Root Planing $247 $138 $210 $185 $124
IV. Orthodontics
Adults $7,025 $3,658 Not Covered Not Covered Not Covered
Children $6,552 $3,422 Not Covered Not Covered Not Covered
Plan Document    Discount Program

Choice PPO Basic

 

Additional Plans 

Benefit FeaturesSelect Plan PremiumChoice PPO PremiumElite ePPO Premium
Office Visit$10None  None
DeductiblesNone  $50 per adult (adult max $150)4$25 per adult (adult max $75)4
Annual MaximumsNone  $1,500 per insured person  $1,500 per insured person
Waiting PeriodsNoneYes5None
Receive Care FromSelect Plan Network DentistElite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (GA, NJ, OR) or any licensed dentistElite ePPO Network Dentist
States AvailableDC, DE, MD, NJ, PA, VAAllDC, MD, PA, VA
Procedures and Covered Services  Avg. Cost 
Without Plan1
You Pay1You Pay1You Pay
I.  Diagnostic & Preventive
Comprehensive Oral Exam$85$0$0$0
Bitewing X-Rays (4 Films)$74$0$0$0
Teeth Cleaning (Adult)$102$0 $0$0
Topical Fluoride for Children$41$0$0$0
II. Basic Restorative
Filling (3-Surface Silver)$217$58$43$40
Complete Series X-Rays$161$26$0$0
III. Major Restorative
Crown (Porcelain/Metal)$1,299$495$650$570
Complete Denture$1,785$664$893$560
Root Canal (Anterior Tooth)$747$325$374$550
Perio Scaling/Root Planing$247$105$124$97
IV. Orthodontics
Adults$7,025$3,658Not CoveredNot Covered
Children$6,552$3,422Not CoveredNot Covered
Plan Document   Select Plan PremiumChoice PPO PremiumElite ePPO Premium



1 Approximate costs and payment amounts based on the Context4Healthcare's 80th percentile. Based on zip 223. A specific fee schedule applies and will be mailed with your membership card.
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. Year 3 benefits apply during the subscriber's third 12 months of continuous coverage.
3 Deductibles apply to all services.
4 Deductibles apply to basic care and major restorative care.
5 There are no waiting periods for diagnostic and preventive care and basic care. To be eligible for major restorative care, you must have completed 6 (twelv) months of continuous coverage. Waiting period credit will be given for the length of time an insured was covered under each benefit classification under the current employer's prior dental coverage.