RFP_26-041-DJ_Appendix F_Option IV_DPPO High Plan - draft.xlsx

This is a benefit comparison worksheet for Appendix F of RFP 26-041/DJ, outlining coverage details for a Dental Preferred Provider Organization (DPPO) High Plan option for the State of Florida's Multiple Option Dental Program. The document specifies comprehensive dental benefits across diagnostic, preventive, basic, major restorative, orthodontic, and implant services, detailing coverage percentages, limitations, and exclusions for both in-network and out-of-network services. Diagnostic services, including radiographs, oral evaluations, and periodontal assessments, are covered at 100% in-network and 90% out-of-network with specified frequency limitations. Preventive services such as prophylaxis, fluoride treatments, and sealants are also covered at these same rates, limited primarily to pediatric populations where applicable. The plan establishes distinct cost-sharing structures, with basic services including amalgam and composite restorations covered at 80% in-network and 70% out-of-network, while major restorative services covering endodontics, periodontics, oral surgery, implants, fixed and removable prosthetics are reimbursed at 50% in-network and 40% out-of-network.

The DPPO High Plan incorporates numerous utilization controls and exclusions designed to manage benefit costs, including frequency limitations (such as two prophylaxis per 12 months), lifetime restrictions on certain surgical procedures, and specific exclusions for services deemed non-essential or overlapping in function. Orthodontic services for members under age 19 are uniquely covered at 50% both in-network and out-of-network, with limitations on appliance therapy to one occurrence per 60 consecutive months. Adjunctive services, including anesthesia and sedation, are covered at 50% in-network and 40% out-of-network but only when medically necessary for specific conditions such as local anesthesia toxicity, mental retardation, Alzheimer's disease, or spastic muscle disorders. The benefit structure reflects a comprehensive yet controlled approach to dental coverage, balancing preventive and basic care access with managed major restorative service utilization through frequency limitations, lifetime restrictions, and selective coverage criteria.