Name: Select Plan Premium
Brand: Dominion National

Sample Quote: Enter your census information for a personalized quote.

person 20001 | Applicant,35 edit

$20.36 /mo.

Dentist Search

Select Plan Premium

Plan Type DHMO

Dentist Search

$20.36 /mo.

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Plan Highlights

Select Plan Premium benefits include:

No waiting periods and plan maximums
No charge for oral exams
Offers better coverage than Dominion basic plan
No CHARGE for routine semiannual cleanings (additional cleaning is covered for expecting mothers and diabetics)
No charge for bitewing X-rays
Discount on all implant services

These procedures account for over 65% of dental services for most frequently performed for adults, and over 90% of the most frequently performed services for children (Based on Dominion’s annual review of utilization data).

See Fee Schedule for Select Plan Premium 705xa benefits here

Select Plan Premium Kids benefits include:

No charge for exams, cleanings, bitewing X-rays and other preventive services
Discount on non-medically necessary orthodontia.

See Fee Schedule for Select Plan Premium Kids (under age 19) benefits here

Common Procedures

Details

Fee Schedule | Dentist Search

Exams: No charge for Periodic oral examination twice per calendar year per person
Office visit copay – $10

Cleanings: No charge for Adult Prophylaxis (cleaning) twice per calendar year per person

X-Rays: No charge for bitewing x-rays – 1 to 4 films, twice per calendar year per person
$30 for panoramic film once in three (3) years per person

Fillings: $37 for Amalgam filling-one surface, primary or permanent
$64 for (white filling) Resin based composite-one surface, anterior
$68 for Resin based composite-one surface, posterior

Extractions: $63 for (Simple) Extraction, erupted tooth or exposed root

Crowns: $495 for crown-porcelain fused metal
$531 for crown – porcelain/ceramic substrate
See complete fee schedule for different types of crowns covered

Root Canals: $325 for endodontic (root canal) therapy-anterior
$488 for endodontic (root canal) therapy-molar

Dentures: $664 for complete denture (maxillary)
$664 for complete denture (mandibular)

Deep Cleanings: $66 for Periodontal maintenance

Implants: All Implant Services – 15% Discount

Braces / Orthodontia: $3,658 for comprehensive orthodontic treatment – adult dentition.
$3,422 for comprehensive orthodontic treatment – adolescent dentition.

Teeth Whitening: Not covered service

Additional Network Information:

You may choose any of the conveniently located dental offices from the list of participating dentists. Each family member may select a different participating dentist. Specialty care is covered on this plan. The fees apply only when services are performed by your selected general dentist. Plan Specialist, if available, will reduce fees 25% from Usual, Customary, and Reasonable (UCR) fees, except in the State of Delaware. In Delaware, Plan Specialists will provide a reduction from their UCR that will vary between specialists.

Exclusions and Limitations
Privacy Policy
Plan Brochure: N/A

FAQ

Can I change my dentist once I am in the plan?

You may change your selected dentist any time by contacting Member Service Department. If notification is received by Dominion National by the 20th of the month the change will be effective on the first of the following month. All outstanding bills with the current dental office MUST be paid before the change will be made effective.

What is a pre-existing condition versus work-in-progress? Is it covered?

What provider options do I have?

When can I start using my Plan?

When will I receive my new member kit and what will it include?

Who can enroll in this plan?

251 18th Street South
Suite 900
Arlington, VA 22202

Disclaimers & Disclosures

This website provides a very brief description of some of the important features of this plan. It is not the insurance contract, nor does it represent the insurance contract. A full description of benefits, exclusions and limitations is contained in the Schedule of Benefits and your policy.

Rates shown are based upon the information you provided, and are subject to change based on the dental and/or vision plan's underwriting practices and your selection of available optional benefits, if any. Final rates and effective dates are subject to underwriting and are always determined by the dental insurance and/or vision insurance company. To be considered for reimbursement, expenses must qualify as covered expenses.

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