TransSmile®

Group Dental Insurance

 

 

Window World Benefit Plans

Choices..Options...Convenience...

Woman brushing her teeth picWoman brushing her teethText Box: Type 1 - Diagnostic and Preventative Services - Pays 80%
Routine periodic examinations not more than once in any six consecutive month period, inclusive of an initial oral examination.
Prophylaxis (cleaning) not more than once in any six consecutive month period.
Topical application of fluoride once in any 12 consecutive month period for dependent children 15 years of age and under.
Bitewings one set in any 12 consecutive month period.
Sealants once per tooth on permanent maxillary and mandibular first and second molars with no caries (decay) on the occlusal surface, for dependent children 14 years of age or under.
Space maintainers for prematurely lost teeth of eligible dependent children 13 years of age and under.

Type 2 - Basic Restorative Services - Pays 50%
Minor emergency treatment for the relief of pain as needed by the Participant.
Amalgam (silver) and composite/resin (white) fillings (composites are not a covered benefit on molars). 
Periapical X-rays four in any 12 consecutive month period.
Full-mouth X-rays once in any five year period.
Simple Extractions

Type 3 - Major Restorative Services - Pays 50%
Endodontics includes pulpal therapy and root canal filling.
Oral Surgery, including pre- and post-operative care and surgical and simple extractions, except TMJ surgery.
Surgical Periodontics includes surgical procedures for the disease of the gums and bone supporting the teeth.
Non-Surgical Periodontics includes surgical procedures for the disease of the gums and bone supporting the teeth.
Periodontal Maintenance once in any six-month consecutive benefit period following active periodontal treatment.
Stainless Steel Crowns used as a restoration to natural teeth for dependent children 15 years of age and under when the teeth cannot be restored with a filling material.
Crowns, Inlays, Onlays, and Veneers are benefits for the treatment of visible decay and fractures of tooth structure when teeth are so badly damaged they cannot be restored with amalgam or composite restorations.
Complete or Partial Denture Reline chair side or laboratory procedure to improve the fit of the appliance to the tissue (gums).
Complete or Partial Denture Rebase laboratory replacement of the acylic base of the appliance.
Repairs to Complete and Partial Dentures
Prosthodontics procedures for construction of fixed bridges, partial or complete dentures.
Implants are payable as a less expensive alternative benefit to prosthodontics and only to replace a tooth or teeth that were extracted while covered under the Policy.


Maximum SmileSM Benefit
Roll forward a portion of each family member’s unused base plan annual maximum into a MaximumSmile Account, subject to the Threshold Limit ($250) and the MaximumSmile Account Limit ($500).  The MaximumSmile account can then be used in future years when the member reaches the Base Plan Annual Maximum.  
To qualify for the MaximumSmile Benefit:
You must have a qualifying claim and not exceed the paid claims Threshold during the benefit year.  Each family member has his or her own separate MaximumSmile Account and may not exceed the MaximumSmile Account Limit.
New entrants joining the plan in mid-policy year becomes eligible for the program at the nest policy anniversary date.
Annual Roll Forward Amount: $125

Deductible Per Person, No Deductible on Type 1 Benefits:	$   50.00
Calendar Year Benefit Maximum Per Person: 		$ 500.00
Transamerica Life Insurance Company Logo

TransSmile® Limitation and Exclusions

Underwritten by Transamerica Life Insurance Company, Home Office Cedar Rapids, IA/

Administered by Omega Administrators, Sherwood, AR

Policy Form CPDEN100 and CCDEN100

 

Covered Dental Expenses do not include, and no benefits are provided, for the following:

1. Services which are not included in the List of Covered Dental Services; which are not necessary; or for which a charge would not have been made in the absence of insurance.

2. Any Service which may not reasonably be expected to successfully correct the Insured Person’s dental condition for a period of at least 3 years, as determined by Us.

3. Any Service provided primarily for cosmetic purposes. Facings on crowns or bridge units on molar teeth and composite resin restorations on molar teeth will always be considered cosmetic.

4. Implants; charges for the insertion of implants or related appliances; or the surgical removal of implants (unless the Policy includes the Implant Benefits Rider).

5. Athletic mouth guards; myofunctional therapy; infection control; precision or semi-precision attachments; denture duplication; oral hygiene instruction; separate charges for acid etch; broken appointments; treatment of jaw fractures; orthognathic surgery; completion of claim forms; exams required by a third party other than Transamerica Life Insurance Company; personal supplies (e.g., water pik, toothbrush, floss holder, etc.); or replacement of lost or stolen appliances.

6. Charges for travel time; transportation costs; or professional advice given on the phone.

7. Orthodontic treatment (unless the Policy includes the Orthodontic Benefits Rider).

8. Services that are a covered expense under any other plan that is provided by the Policyholder and under which You are eligible for coverage.

9. Services performed by a Dentist who is member of the Insured Person’s family. Insured Person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents.

10. Any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility.

11. Any Service required directly or indirectly to diagnose or treat a muscular, neural, or skeletal disorder, dysfunction, or disease of the temporomandibular joints or their associated structures (unless the Policy includes the TMJ Benefits Rider).

12. Any charge for a Service performed outside of the United States other than for Emergency Treatment. Benefits for Emergency Treatment performed outside of the United States are limited to a maximum of $100 per year per Insured Person.

13. Any charge for a Service required as a result of disease or injury that is due to war or an act of war (whether declared or undeclared); taking part in an insurrection or riot; the commission or attempted commission of a crime; an intentionally self-inflicted injury or attempted suicide while sane or insane.

14. Any charge for a Service for which benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, even if the Insured Person did not purchase the coverage that is available.

15. Any Service for which the Insured Person is not required to pay, unless the payment of benefits is mandated by law and then only to the extent required by law.

16. Benefits to correct congenital or developmental malformations.

17. Charges for services when a claim is received for payment more than 12 months after services are rendered.

18. Charges for complete occlusal guards, enamel microabrasion, odontoplasty, and bleaching.

19. For specialized techniques that entail procedure and process over and above that which is normally adequate, any additional fee is the Participant’s responsibility.

20. Behavior management.

21. Charges for general anesthesia/intravenous sedation are not covered, except when administered in conjunction with covered oral surgery and unusual medical circumstances require the use of general anesthesia as determined by Our Administrator’s dental consultants.

22. Charges for desensitizing medicines, home care medicines, premedications, stress breakers, coping, office visits before or after regularly scheduled hours, case presentations, and hospital-related services.

23. Charges for treatment by other than a Dentist except that a licensed hygienist may perform services in accordance with applicable law. Services must be under the supervision and guidance of the Dentist in accordance with generally accepted dental standards.

24. Benefits for services or appliances Started prior to the date the Person became eligible under this plan, including, but not limited to, restorations, prosthodontics, and orthodontics.

25. Services for increasing the vertical dimension or for restoring tooth structure lost by attrition, for rebuilding or maintaining occlusal services, or for stabilizing the teeth.

26. Experimental and/or investigational services, supplies, care and treatment which do not constitute accepted medical practice within the range of appropriate medical practice under the standards of the case and under the standards of a qualified, responsible, relevant segment of the medical and dental community or government oversight agencies at the time services were rendered. Drugs are considered experimental if they are not commercially available for purchase or are not approved by the Food and Drug Administration for general use.

27. Services for the replacement of a Missing Tooth.

Weekly Premiums

Employee Only

$4.94

Employee + Spouse

$9.62

Employee + Children

$10.44

Family

$16.14