Choice PPO Preventive

66759NC0010004
Low
PPO

Choice PPO Preventive is a Low PPO plan by Dominion National.

Locations

Choice PPO Preventive is offered in the following counties.

Plan Overview

This is a plan overview for 2025 version of Choice PPO Preventive 66759NC0010004.
Insurer: Dominion National
Network Type: PPO
Metal Type: Low
HSA Eligible?:
Plan ID: 66759NC0010004

Cost-Sharing Overview

Choice PPO Preventive offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Choice PPO Preventive?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Choice PPO Preventive offers the following features and referral requirements.

Wellness Program:
Disease Program:
Notice Pregnancy:
Referral Specialist:
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Choice PPO Preventive covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Standard Out of Network PPO Benefits
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Standard Out of Network PPO Benefits
National Network: Yes

Additional Benefits and Cost-Sharing

Choice PPO Preventive includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Routine Dental Services (Adult)
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible Subject to deductible of $50/individual and $150/three or more adults. Benefit limitations may apply to individual services.
Dental Check-Up for Children
Covered
Not Applicable 100.00%Not Applicable 80.00%2.0 Visit(s) per Benefit Period
Basic Dental Care – Child
Covered
Not Applicable 65.00% Coinsurance after deductibleNot Applicable 80.00% Coinsurance after deductible
Orthodontia – Child
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Major Dental Care – Child
Covered
Not Applicable 75.00% Coinsurance after deductibleNot Applicable 90.00% Coinsurance after deductible
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Accidental Dental
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following Choice PPO Preventive preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for Choice PPO Preventive?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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