The Premier Plan.

$1,950 / annual benefit
per member/per year

$67.75 per Month for Single Member Only
$130.08 per Month for Single Member + Child(ren)
$130.08 per Month for Single Member + Spouse
$210.03 per Month for Family

Deductible Information:

Preventative + Diagnostic Services: No Deductible
Basic + Major Restorative Services: $50 Per Member/$150 Per Family Per Year

Network Details:

Bento Network (Platinum, Gold, Silver) DenteMax PPO and Connection Dental PPO

Preventative + Diagnostic Services

100% Coverage In-Network | 100% Coverage Out-of-Network*

ORAL EVALUATIONS

  • Comprehensive evaluation, once every 60 months

  • Periodic oral evaluations, twice in a 12 month period from first date of service

  • Limited evaluation, once in 12 months, does not share frequency with periodic

    evaluation

X-RAYS

  • Single tooth periapical x-rays, as required • Bitewing x-rays; once every 12 months

ROUTINE DENTAL CARE

  • Routine dental cleaning, twice in a 12 month period from first date of service

  • Periodontal cleanings; once every 3 months after active periodontal treatment, not to exceed twice in 12 months if combine with routine cleanings

  • Fluoride treatments, twice in 12 months for members under age 19

Basic Restorative Services

80% Coverage In-Network | 80% Coverage Out-of-Network*

PROSTHETIC MAINTENANCE

  • Repair of partial or complete dentures and bridges; once per 12 months after 24 months of initial insertion.

  • Reline or rebase partial or complete dentures; once within 36 months

  • Recement of crowns, onlays and bridges, once per tooth

FILLINGS

  • Amalgam (silver) fillings; one filling per tooth surface every 24 months

  • Composite resin (white) fillings; one filling per tooth surface every 24 months • Temporary fillings; one filling per tooth


Major Restorative Services (12 Month Waiting Period)

50% Coverage In-Network | 50% Coverage Out-of-Network*

IMPLANTS

  • Endosteal implant (D6010), once per 84 months per implant

  • Custom abutment (D6057), once per tooth in 60 months

  • Abutment supported porcelain/ceramic crown (D6058), once per tooth in 60 months

CROWNS

  • Once per tooth in 60 months.**

ROOT CANAL TREATMENT (ENDODONTICS)

  • Root canals on permanent teeth; once per tooth

  • Vital pulpotomy, limited to deciduous teeth

  • Retreatment of prior root canal on permanent teeth; once per tooth after 24 months have elapsed frominitial treatment

  • Root end surgery on permanent teeth; once per tooth

ORAL SURGERY

  • Simple tooth extractions; once per tooth

  • Erupted or exposed root removal; once per tooth

  • General anesthesia or intravenous sedation for complex surgical procedures


OTHER DENTAL SERVICES

  • Dental care to relieve pain (palliative care), 4 occurrences in 12 months

  • Sealants for children under 16, once per unrestored permanent molar every 36 months

  • Space maintainers for lost deciduous (baby) teeth, replacement limited to once every 60 months

  • Full mouth x-rays; once every 60 months

  • Panoramic x-ray; once every 60 months


TOOTH REPLACEMENT (PROSTHODONTICS)

  • Removable complete or partial dentures, including services to fabricate, measure, fit, and adjust them; once in 60 months

  • Fixed bridges and crowns (when part of a bridge), including services to fabricate, measure, fit, and adjust them; once per tooth in 60 months

  • Replacement of dentures and bridges, but only when they are installed at least 60 months after the initial placement and only if the existing appliance cannot be made serviceable

  • Temporary partial dentures to replace any of the six upper or lower front teeth, but only if they are installed immediately after the loss of teeth and during the period of healing

  • Single tooth dental endosteal implants when the implant replaces permanent teeth through second molars; once per tooth in 60 months

    GUM TREATMENT (PERIODONTICS)

    • Periodontal scaling and root planing; one per quadrant in 24 months. All four quads can be completed same day

    • Periodontal surgery; once per quadrant in 36 months

Plan year: 12 Months from Coverage Start Date

*Patient is responsible for charges above the allowable amounts. See above for network details and provider information.

** Dentists, go to dentists.bento.net to look up code coverage and exclusions.

Bento is a proud partner of the DenteMax PPO and ConnectionDental PPO networks giving you even more options for dental providers.

The Bento Network

MEMBERS: As a Bento Member, you have access to the entire national Bento Network which includes contracted rates for covered services with a no balance billing policy when visiting Bento Dentists and Bento Partner Dentists*. This plan works at ANY licensed dentist in the US; however you get the best rates when going to in-network Bento Dentists and Specialists. Your plan will pay the dentist through Bento for any plan payments.

PROVIDERS: Both in-network (Plus Network, DenteMax PPO and Connection Dental PPO) and out-of-network dentists should submit claims via the Bento Dentist Portal (dentists.bento.net). Claims can be processed and paid via direct deposit (fastest) or check.

For assistance accessing the Bento Dentist Portal contact Bento at smile@bento.net or call 800-734-8484.

Non-Bento Network Coverage (Out-of-Network)

This plan’s payment for services received from Non-Bento Dentists (out-of-network) is based on either the dentist’s fee or MAC, whichever is lower. Bento Members that utilize the services of a Non-Bento Dentist whose fees are higher than the MAC fee for that region, will be responsible for the difference between the plan payment and the dentist’s total submitted charges.

Processing Fee for Non-Portal Reimbursements
Bento is not an insurance company and charges a $1.59 processing fee for non-portal reimbursements for practices that do not use Bento’s free checkout option. Bento’s online checkout is the most secure and the fastest way to collect payment for all treatment given to Bento patients and allows for either paper check or ACH. Bento’s portal (dentists.bento.net) is completely free and allows you to check eligibility, generate estimates, and collect payment all in real time without ever having to file an ADA form.

Non-Portal submissions for completed ADA forms:
Mail: Bento | Claims Department | PO Box 9028 | Boston, MA 02114 Fax: (855) 214-4888
ePayer ID: N/A
Group Number: N/A

Patients (Bento Members) are responsible for paying any remaining balances between the plan payment and dentist’s fees. Out-of-network providers can join the Bento Network at any time, setup is quick, free, and easy. Visit bento.net.dentist to learn more.