Individual & Family Plans

Dental

Highlights: TRH Health Plans uses Network DentalBlue Preferred. Please keep in mind that in-network payments are based on negotiated fees. If an out-of-network provider is used, the member’s liability will increase significantly.

About the Plan

With a TRH dental plan, individuals and families get affordable financial protection for not only preventive services and routine exams, but a more extensive range of services over time.  
 

Download Schedule of Benefits

Overview

  Copayment Benefits
Benefits available after 90 days $15 copayment per examination-100% of maximum allowable charge
  • Two routine periodic examinations in any 12-month period.
  • Bitewing X-rays once in every 12-month period.
  • Full mouth X-rays once in any 36-month period.
  • Topical fluoride application for members under age 19, once in any 12-month interval.
  • Prophylaxis and periodontal maintenance, not to exceed 2 per year.
  • Any combination of exams -- initial, periodic emergency or periodontal -- limited to 3 times in a 12-month period.
Benefits available after 12 months $15 copayment for each of the following services – 100% of the maximum allowable charge
  • Sealants, only for occlusal (biting) surface of first and second permanent molar teeth on members under 16 years of age. Only 1 sealant benefit will be allowed on each tooth per lifetime of coverage. The copayment applies per tooth for this service.
$25 copayment for each of the following services – 100% of the maximum allowable charge
  • Emergency treatment for relief of pain.
  • Restorative services: filling material such as amalgam, synthetic porcelain and composite restorations--limited to 1 restoration per surface per tooth per year. The copayment applies per tooth for this service.
  • Oral surgery: provides for routine extractions (non-impacted), including pre- and post-operative care. The copayment applies per tooth for this service.
  • Repair of full and partial dentures after 12 month initial placement. The copayment applies per procedure – upper and lower dentures are considered separate procedures.
  • Stainless steel crowns. The copayment applies per tooth for this service.
  • Bridge repair after 6 month initial placement. The copayment applies per procedure.
  • Crown repair after 6 month initial placement. The copayment applies per procedure.
$75 copayment for each of the following services - 100% of the maximum allowable charge
  • Endodontics: root canal treatment. The copayment applies per tooth for this service.
  • Periodontics: treatment for diseases of the gums and bones supporting teeth. The copayment applies per procedure.
  • Surgical extractions (impactions). The copayment applies per tooth.
  • Space maintainers for members up to age 14. The copayment applies per procedure.
  • Relining and rebasing of full and partial dentures limited to 1 upper and 1 lower every 3 years. Separate copayments for upper and lower.
Benefits available after 24 months $75 copayment for each of the following services - 50% of the maximum allowable charge
  • Full and partial upper and lower dentures. Separate copayments for upper and lower.
  • Benefits will be provided for any necessary adjustments for a 6-month period.
  • Initial placement of fixed and removable bridges by standard procedure. The copayment applies per tooth.
  • Cast crowns for treatment of severe carious lesions or severe fracture when the tooth cannot be restored with amalgam, synthetic porcelain or composite restorations. The copayment applies per tooth.
  • Cast inlays/onlays (copayment per tooth).
  • Laminate veneers (copayment per tooth).
Annual maximum benefit $1,500 per member