The sample table above is a small selection of common procedures covered by the CA90 plan. Once enrolled, you will be provided with a complete fee schedule with discounted fees for nearly every dental procedure. All procedures covered under the Liberty CA90 Reduced Fee Dental Plan offer similar savings to the sample above.
1 Source: DentalPlans.com (DP.C) 2007 Survey of Sample Average National Dental Fees. Fees may vary slightly by region.
2 Discounted fees are listed for visits to a participating general dentist - this fee is guaranteed according to your fee schedule. Consult with your provider prior to beginning any treatment. $10.00 office visit charge applies.
- Prophylaxis are discounted once every six months.
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Full Mouth X-rays are limited to once every 36 months.
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Members: see your complete fee schedule for limitations and exclusions.
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A referral is required to see a participating specialist.
* Base metal is the benefit. Noble, high noble metal, or titanium, if used, will be charged to the member at the additional laboratory cost of the noble, high noble, or titanium metal.
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Resin, porcelain and any resin to metal or porcelain to metal crowns and pontics are a benefit on anterior and bicuspid teeth only.
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LIBERTY Dental Plan will arrange for you to receive services from a contracted dental specialist if the necessary treatment is outside the scope of general dentistry. Your general dentist will initiate the referral process with LIBERTY Dental Plan. The proper referral process must be utilized for specialty services to be covered under your plan. The member copayments listed under 'Specialty Fee' will apply when services are performed by a LIBERTY Dental Plan specialist. X-rays for diagnostic purposes are benefits in the general dentist's office only.