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Summary of Dental BenefitsHDS Preferred Dental Plan - Group No. 2851Effective: 01/01/2021This summary is a brief description of a Hawaii Dental Service (HDS) member's dental benefits. Some limitations, restrictions,and exclusions may apply. Plan benefits are governed by the provisions detailed in the group's and/or subscriber's agreementwith HDS, HDS's Procedure Code Guidelines and Delta Dental National Policies when applicable. Certain provisions may varysuch as waiting periods, frequency and age limitations, etc. and may not be included in this summary. For additionalinformation, please contact HDS Customer Service. As an HDS member, you may visit any licensed dentist, but your out-ofpocket costs may be lower when visiting an HDS participating dentist. All dental claims must be filed within 12 months of thedate of service to be eligible for HDS claims payment.ADULTS (& CHILD ages 19 - 25)PLAN MAXIMUM 1000 per person per calendarCHILDREN (AGE 18 & UNDER)MAXIMUM OUT OF POCKET (MOOP) 350 per childyear. The most HDS will pay for each person for allor 700 for 2 or more children, per calendar year. Thecovered dental services performed during themost you will pay before your dental plan begins tocalendar year.pay 100% of your benefit. Out-of-pocket paymentsDIAGNOSTIC & PREVENTIVE WAIVER HDS'smade for non-covered services, alternate benefits andpayment for Diagnostic and Preventive services willnon-medically necessary orthodontics will not countnot be deducted from the member's Plan Maximum.toward the MOOP.DEDUCTIBLE 50 per person, per calendar year.DEDUCTIBLE 50 per person, per calendar year.Does not apply to benefits covered at 100% andDoes not apply to benefits covered at 100% sHDS PLAN PAYSADULTS (& CHILD ages 19 - 25)CHILDREN (AGE 18 & UNDER)100%100%2x/yrBitewing X-raysOther X-raysPREVENTIVECleaningsFluorideSilver Diamine FluorideSpace Maintainers2x/yr50%30%1x/yr2x/yr50%30%Full mouth X-rays 1x/5 yrsFull mouth X-rays 1x/5 yrs100%100%2x/yr2x/yrNot Covered100%N/A2x/yrThrough age 18100%100%Not Covered100%Through age 18SealantsOne treatment per tooth perlifetime to permanent molarteeth when there are no priorfillings on biting surfaces.Not Covered100%Through age 18
TOTAL HEALTH PLUSBENEFITSIf the member has multiple conditions, the member will only be eligible for the benefit with the mostcleaning(s) and/or gum maintenance treatments of a single condition. All benefits are covered at 100%unless otherwise noted.Diabetes Cleanings/Gum MaintenanceCancer (other than Oral) Cleanings/Gum Maintenance Fluoride TreatmentsOral Cancer Cleanings/Gum Maintenance Fluoride TreatmentsSjogren's Syndrome Cleanings/Gum Maintenance Fluoride TreatmentsStroke Cleanings/Gum MaintenanceHeart Attack, CongestiveHeart Failure Cleanings/Gum MaintenanceKidney Failure Cleanings/Gum MaintenanceOrgan Transplant Cleanings/Gum MaintenancePregnancy (ExpectantMothers) Cleanings/Gum MaintenanceMedical Risk for Cavities Fluoride TreatmentsBASIC CAREFillingsOnce every two years per toothper surface.Root CanalsAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 4x/yrAdditional 2x/yrAdditional 4x/yrAdditional 2x/yrAdditional 4x/yrAdditional 2x/yrAdditional 4x/yrAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 2x/yrAdditional 1x/yrAdditional 1x/yrAdditional 3x/yrAdditional 3x/yr50%30%3 mo wait periodWhite-colored fillings limited to front teeth. White-colored fillings limited to front teeth.50%30%12 mo wait periodGum/Bone Surgeries &Maintenance (non-medical risk50%30%12 mo wait periodfactors)Once every three years perquad.Oral Surgeries50%12 mo wait period30%
MAJOR CARECrowns50%30%1x/7yrs per tooth1x/7yrs per tooth12 mo wait periodWhite crowns limited to front teeth andbicuspids.White crowns limited to front teeth andbicuspids.50%30%1x/7yrs per tooth12 mo wait period1x/7yrs per toothOTHER SERVICESAdjunctive General Services50%30%Emergency Treatment of50%Fixed Bridges & Dentures30%Nitrous Oxide, IV sedation and hospital careis covered.Dental Pain (PalliativeTreatment)Once per visit per dental officefor relief of pain but not to cureAthletic Mouth GuardsNot Covered30%1x/24-monthsThrough age 18ORTHODONTICSMedically Necessary OrthoLimited to dependent children50%50%For children. 1000 lifetime maximum amount paidFor children. 1000 lifetime maximum amount paid(eight quarterly payments)(eight quarterly payments)Not Covered50%Through age 18for those cases involving repairof the cleft lip and/or cleftpalate, severe facial birthdefects, or an incurred injurythat affects the function ofspeech, swallowing, and/orchewing.ADULTS (& CHILD ages 19 - 25) - Special Consideration: Assessment of salivary flow is covered.Orthodontic services are not covered if services were started prior to the date the patient became eligibleunder this plan. If a patient's eligibility ends prior to the completion of the orthodontic treatment, paymentswill not continue. Self-administered or at-home applications (or any type of "do it yourself") orthodontics isnot a covered benefit. Orthodontics must be performed by a licensed dentist or supervised staff.CHILDREN (AGE 18 & UNDER) - Special Consideration: Assessment of salivary flow is covered.Orthodontic services are not covered if services were started prior to the date the patient became eligibleunder this plan. If a patient's eligibility ends prior to the completion of the orthodontic treatment, paymentswill not continue. Self-administered or at-home applications (or any type of "do it yourself") orthodontics isnot a covered benefit. Orthodontics must be performed by a licensed dentist or supervised staff.05/29/2020
We’regivingyou moreto smileabout.Total Health Plussupplemental benefits designed for members in need of extra careWe just upgradedyour dental plan tohelp you live welland smile more.We understand some people need moreoral health services to maintain total bodyhealth. That’s why we’ve upgraded yourdental plan to include Total Health Plus,a supplemental set of benefits tailored tocertain medical conditions or diagnoses.
What can Total Health Plus dofor me and my family?HDS Total Health Plus Benefits providesadditional coverage for members with:DiabetesStroke& HeartProblemsOralCancerCancerMedicalRisk forCavitiesKidneyFailureDesigned for PreventionHDS Total Health Plus gives you access tomore services and shares the importanceof maintaining good oral health care. Thissupplemental set of benefits is essentialto improving your overall health and isdesigned to prevent oral disease and toothdecay that accompanies certain medicalconditions or diseases. Contact yourdentist to see if you qualify for Total HealthPlus benefits.Contact UsPhone(808) 529-9248 or call toll-free at TransplantsSjögren’sSyndromea disorder of theimmune systemcausing dry mouthPregnancyTo create and view your account online, visit:HawaiiDentalService.comFollow usHDS Total Health Plus BenefitsMedical Condition or DiagnosisBenefitFrequencyCleaningstwo additional per yearCancer (or history of cancer or undergoing treatment suchas chemotherapy or radiation; not including oral cancer)CleaningsFluoride Treatmentstwo additional per yeartwo additional per yearOral Cancer (or history of oral cancer or undergoingtreatment for oral cancer)CleaningsFluoride Treatmentstwo additional per yearfour additional per yearSjögren’s SyndromeCleaningsFluoride Treatmentstwo additional per yearfour additional per yearStroke (or history of stroke; TIA - Transient Ischemic Attack)Cleaningstwo additional per yearHeart Attack, Congestive Heart Failure(orCleaningstwo additional per yearKidney Failure (or history of renal failure or dialysis)Cleaningstwo additional per yearOrgan Transplants (or history of organ transplants)Cleaningstwo additional per yearPregnancy (expectant mothers)Cleaningsone additional per yearFluoride Treatmentsthree additional per yearDiabetes(or history of diabetes)(or history of Sjögren’s Syndrome)history of heart attack; MI - Myocardial Infarction)Medical Risk for CavitiesAll benefits listed above are covered at 100%.
Summary of Dental Benefits HDS Preferred Dental Plan - Group No. 2851 Effective: 01/01/2021 This summary is a brief description of a Hawaii Dental Service (HDS) member's dental benefits. Some limitations, restrictions, and exclusions may apply. Plan benefits are governed by the provisions detailed in the group's and/or subscriber's agreement
