Benefit Reference Guide - The School District of Palm Beach County

BENEFIT
Deductible
Dental
Commonly Covered Procedures - Managed Care Plans (S500PB & S700)
Option 1
Plan S500PB
Option 2
Plan S700
Yearly Deductible None None
Calendar Year Maximum None None
Claim Forms None None
Rosters None None
Primary Dentist Required None None
Diagnostic/Preventive You Pay You Pay
Office visit
Routine exams
Prophylaxis (cleaning) - basic
Emergency treatment (Palliative)
X-ray and complete series including bitewings
Fluoride application
Basic/restorative procedures***
Simple extractions
Amalgam fillings - 1 surface permanent
Root Canals (1 canal)
Root Canal (3 canals)
Sealants (age limit applies)**
Major procedures
Crowns - porcelain, base metal**
Dentures - upper/lower**
Bridges - porcelain base metal**
Periodontics
Scaling and root planing per year
Orthodontics
No Charge
No Charge (1 per 6 months)
No Charge (1 per 6 months)
No Charge
No Charge (1 per 60 months)
No Charge (1 per 12 months)
$10
No Charge
$100
$225
No Charge
$240
$260 each
$240
$45 per quadrant
(limit 2 per year)**
No Charge
No Charge (1 per 6 months)
No Charge (1 per 6 months)
No Charge
No Charge (1 per 60 months)
No Charge (1 per 12 months)
$20
No Charge
$110
$245
No Charge
$245
$325 each
$245
$50 per quadrant
(limit 2 per year)**
Pre-orthodontic treatment visit $0 $35
Comprehensive treatment of transitional dentition $1,600 $2,200
Comprehensive treatment of adolescent transitional dentition $1,600 $2,250
Comprehensive treatment of adult dentition $1,950 $2,350
** See exclusions and limitations.
***Surgical removal of impacted tooth provided at a 25% reduction off specialist’s usual
and customary fee when pathology does not exist. When pathology exists your Co-pay
will apply with approved referral.
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