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Dental Benefits For Everyone.

Which plan is right for you?

Below you can compare coverage for Dominion's adult plans (age 19 and over). For more details, you can view the adult and pediatric 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.

Benefit Features Select Plan Basic 1 PPO Preventive PPO Basic
Office Visit $10 N/A N/A
Deductibles None $50 per adult (adult max $150)3 $50 per adult (adult max $150)3
Annual Maximums None None $1,000 per insured person
Waiting Periods None None None
Receive Care From Select Plan Network Dentist Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (GA, OR) or any licensed dentist Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (GA, OR) or any licensed dentist
States Available DC, DE, MD, PA, VA DC, DE, GA, MD, OR, PA, VA DC, DE, GA6, MD, OR, PA, VA
Procedures and Covered Services In-Network In-Network Year 1 2
In/Out Network
Year 2 2
In/Out Network
Year 3 2
In/Out Network
I.  Diagnostic & Preventive          
Comprehensive Oral Exam 100% 100% | 80% 100% | 90% 100% | 90% 100% | 90%
Bitewing X-Rays (4 Films) 100% 100% | 80% 100% | 90% 100% | 90% 100% | 90%
Teeth Cleaning (Adult) 90% 100% | 80% 100% | 90% 100% | 90% 100% | 90%
II. Basic Restorative          
Full and panoramic X-rays 85% 100% | 80% 50% | 30% 60% | 50% 80% | 70%
Amalgam filling (silver) 80% 0% | 0% 50% | 30% 60% | 50% 80% | 70%
Composite filling (white) 70% 0% | 0% 50% | 30% 60% | 50% 80% | 70%
Extraction, erupted tooth 70% 0% | 0% 50% | 30% 60% | 50% 80% | 70%
III. Major Restorative8          
Crown (Porcelain/Metal) 60% 0% | 0% 15% | 10% 25% | 20% 50% | 40%
Bridges 65% 0% | 0% 15% | 10% 25% | 20% 50% | 40%
Complete Denture 70% 0% | 0% 15% | 10% 25% | 20% 50% | 40%
Relining of dentures 65% 0% | 0% 15% | 10% 25% | 20% 50% | 40%
Periodontics (root planing and therapy) 70% 0% | 0% 15% | 10% 25% | 20% 50% | 40%
Endodontics (root canals) 70% 0% | 0% 15% | 10% 25% | 20% 50% | 40%
Oral Surgery (extraction of impacted teeth) 70% 0% | 0% 15% | 10% 25% | 20% 50% | 40%
IV. Orthodontics
Adults 45% 0% | 0% 0% | 0% 0% | 0% 0% | 0%
Plan Document

Select Plan Basic

Select Plan Basic Kids

PPO Preventive

PPO Basic Kids

PPO Basic

PPO Basic Kids

 

Additional Plans

Benefit Features Select Plan Premium 1 PPO Plus PPO Premium Elite ePPO Basic 
Office Visit $10 None None None
Deductibles None $50 per adult (adult max $150)3 $50 per adult (adult max $150)4 $25 per adult (adult max $754
Annual Maximums None $750 per insured person $1,500 per insured person $1,500 per insured person
Waiting Periods None None Yes5 None
Receive Care From Select Plan Network Dentist Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (GA, OR) or any licensed dentist Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (GA, OR) or any licensed dentist Elite ePPO Network Dentist
States Available DC, DE, MD, PA, VA DC, DE, GA, MD, OR, PA, VA DC, DE, GA, MD, OR, PA, VA DC, MD, PA, VA
Procedures and Covered Services In-Network In/Out Network In/Out Network In-Network 
I.  Diagnostic & Preventive        
Comprehensive Oral Exam 100% 100% | 90% 100% | 90% 100%
Bitewing X-Rays (4 Films) 100% 100% | 90% 100% | 90% 100%
Teeth Cleaning (Adult) 100% 100% | 90% 100% | 90% 100%
II. Basic Restorative        
Full and panoramic X-rays 85% 100% | 90% 100% | 90% 100%
Amalgam filling (silver) 85% 50% | 40% 80% | 70% 90%
Composite filling (white) 75% 50% | 40% 80% | 70% 90%
Extraction, erupted tooth 75% 50% | 40% 80% | 70% 80%
III. Major Restorative        
Crown (Porcelain/Metal) 60% 0% | 0% 50% | 40% 60%
Bridges 65% 0% | 0% 50% | 40% 60%
Complete Denture 70% 0% | 0% 50% | 40% 75%
Relining of dentures 70% 0% | 0% 50% | 40% 80%
Periodontics (root planing and therapy) 70% 50% | 40% 50% | 40% 70%
Endodontics (root canals) 70% 0% | 0% 50% | 40% 50%
Oral surgery (extraction of impacted teeth) 70% 0% | 0% 50% | 40% 70%
IV. Orthodontics
Adults 45% 0% | 0% 0% | 0% 0%
Plan Document Select Plan Premium

Select Plan Premium Kids

PPO Plus

PPO Basic Kids

PPO Premium

PPO Premium Kids

Elite ePPO Basic

PPO Basic Kids
1 Based on the Context4Healthcare’s 80th percentile. Coverage for orthodontia is based on the 80th percentile of Dominion's out-of-network claims data for D8080 and D8090 (excluding Invisalign) from 2015 to 2018. Based on zip 223. A specific fee schedule applies and will be sent with your membership card. To view copay schedules for the pediatric plans, go to DominionNational.com/pediatric.
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. 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.
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. To be eligible for basic care, you must have completed 6 (six) months of continuous coverage. To be eligible for major restorative care, you must have completed 12 (twelve) 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. 
6 PPO plans in Georgia: out-of-network coinsurance is the same as the in-network coinsurance. Note when using an out-of-network provider, members may incur any charges exceeding the allowed amount. 

 

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.

Benefit Features Select Plan Basic PPO Preventive PPO Basic
Office Visit $10 N/A N/A
Deductibles None $50 per adult (adult max $150)3 $50 per adult (adult max $150)3
Annual Maximums None None $1,000 per insured person
Waiting Periods None None None
Receive Care From Select Plan Network Dentist Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (GA, OR) or any licensed dentist Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (GA, NJ, OR) or any licensed dentist
States Available DC, DE, MD, PA, VA DC, DE, GA6, MD, OR, PA, VA DC, DE, GA6, MD, OR, PA, VA
Procedures and Covered Services Avg. Cost Without Plan1 You Pay  You Pay

You Pay
Year 11,2
In-Network

You Pay
Year 21,2
In-Network

You Pay
Year 31,2
In-Network

I.  Diagnostic & Preventive
Comprehensive Oral Exam $71 $0 $0 $0 $0 $0
Bitewing X-Rays (2 Films) $61 $0 $0 $0 $0 $0
Teeth Cleaning (Adult) $120 $13 $0 $0 $0 $0
II. Basic Restorative
Filling (3-Surface/Silver) $338 $64 Not covered $169 $135 $68
Complete Series X-Rays $189 $26 $0 $95 $76 $38
III. Major Restorative
Crown (Porcelain/Metal) $1,291 $523 Not Covered $1,097 $968 $646
Complete Denture $2,164 $697 Not Covered $1,839 $1,623 $1,082
Root Canal (Anterior Tooth) $1,134 $341 Not Covered $964 $851 $567
Perio Scaling/Root Planing $342 $109 Not Covered $291 $257 $171
IV. Orthodontics
Adults $6,420 $3,658 Not Covered Not Covered Not Covered Not Covered
Plan Document   

Select Plan Basic

Select Plan Basic Kids

PPO Preventive

PPO Basic Kids

PPO Basic

PPO Basic Kids

 

Additional Plans 

Benefit Features Select Plan Premium PPO Plus PPO Premium Elite ePPO Basic
Office Visit $10 None   None   None
Deductibles None   $50 per adult (adult max $150)3 $50 per adult (adult max $150)4 $25 per adult (adult max $75)4
Annual Maximums None   $750 per insured person  $1,500 per insured person   $1,500 per insured person
Waiting Periods None None Yes5 None
Receive Care From Select Plan Network Dentist Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (GA, OR) or any licensed dentist Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (GA7, OR) or any licensed dentist Elite ePPO Network Dentist
States Available DC, DE, MD, PA, VA DC, DE, GA6, MD, OR, PA, VA DC, DE, GA6, MD, OR, PA, VA DC, MD, PA, VA
Procedures and Covered Services   Avg. Cost 
Without Plan1
You Pay You Pay1 You Pay1 You Pay
I.  Diagnostic & Preventive
Comprehensive Oral Exam $71 $0 $0 $0 $0
Bitewing X-Rays (2 Films) $61 $0 $0 $0 $0
Teeth Cleaning (Adult) $120 $0 $0  $0 $0
II. Basic Restorative
Filling (3-Surface Silver) $338 $58 $169 $68 $40
Complete Series X-Rays $189 $26 $0 $0 $0
III. Major Restorative
Crown (Porcelain/Metal) $1,291 $495 Not covered $646 $570
Complete Denture $2,164 $664 Not covered $1,082 $560
Root Canal (Anterior Tooth) $1,134 $325 Not covered $567 $550
Perio Scaling/Root Planing $342 $105 $171 $171 $97
IV. Orthodontics
Adults $6,420 $3,658 Not Covered   Not Covered Not Covered
Plan Document    Select Plan Premium

Select Plan Premium Kids
PPO Plus PPO Premium

PPO Premium Kids
Elite ePPO Basic


1 Based on the Context4Healthcare’s 80th percentile. Coverage for orthodontia is based on the 80th percentile of Dominion's out-of-network claims data for D8080 and D8090 (excluding Invisalign) from 2015 to 2018. Based on zip 223. A specific fee schedule applies and will be sent with your membership card. To view copay schedules for the pediatric plans, go to DominionNational.com/pediatric.
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. To be eligible for basic care, you must have completed 6 (six) months of continuous coverage. To be eligible for major restorative care, you must have completed 12 (twelve) 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.
6 PPO plans in Georgia: out-of-network coinsurance is the same as the in-network coinsurance. Note when using an out-of-network provider, members may incur any charges exceeding the allowed amount.