Membership Plan

Hickman Family Dental Membership Plan

The Hickman Family Dental Membership Plan is designed to provide affordability and greater access to quality dental care.

With your comprehensive dental plan there are:

No Yearly Maximums
No Deductibles
No Claim Forms
No Waiting Periods
No Preauthorization Requirements
No Pre-Existing Conditions

Cost of Dental Plan

SINGLE

$400

(Value $600)

DUAL

$700

(Value $1,200)

FAMILY

$1,200

(Value $3,600)

The family plan includes all children (up to age 18) in the family (up to 4 children)

Coverage Table

Diagnostic & X-Rays

Comprehensive Exam (New Patient, initial visit)
100%
Periodic Exam (2 per year)
100%
Limited Oral Exam, Problem Focused (1 per year)
100%
Intraoral – Complete Series or Panorex
100%
Intraoral – Periapical, First Film
100%
Intraoral – Periapical, Each Additional Film
100%
Intraoral – Occlusal Film
100%
Bitewings (yearly, as needed)
100%

Preventive

Child Prophylaxis (cleaning) (2 per year)
100% (Additional Visits 15%)
Adult Prophylaxis (cleaning) (2 per year)
100% (Additional Visits 15%)
–OR–
Adult Periodontal Maintenance (2 per year)
100% (Additional Visits 15%)
Fluoride (2 per year, no age limit)
100%
Sealants
50%

All Other Procedures

Whitening
25%
Fillings
15%
Crowns
15%
Periodontics (General Denistry)
20%
Dentures and Partials
15%
Oral Surgery (limited to extractions including third molar)
15%
Root Canals
15%
Implants
15%

* This is the percent off the Current Fee Schedule.

little girl smiling and pointing to her teeth

Program Exclusions and Limitations

This program is a discount plan, not a dental insurance plan.

It cannot be used:

In conjunction with dental insurance or another dental plan.
For services or injuries covered under workman’s compensation.
For treatment which, in the sole opinion of the treating dentist, lies outside the realm of his/her capabilities.
For referrals to specialists.
For hospitalization or hospital charges of any kind.
For costs of dental care which are covered under automobile, homeowners, or medical insurance.

Program Guidelines

Your plan’s effective date and record of usage will be on file at Hickman Family Dental. The cost of the Hickman Family Dental Membership Plan and the current fee schedule is subject to change.

The cost of the plan is NON-REFUNDABLE. No refunds will be issued if the patient elects not to utilize. Patients portion of bill is due on day of service. We gladly accept personal checks, Wells Fargo Health Advantage, most credit cards and debit cards, and cash.

Designed to provide affordability and greater access to quality dental care.