Does Preferred One Cover Dental Implants?

Navigating dental insurance can feel like a maze, especially when you are facing a major procedure like a dental implant. You know the implant is the best option for your health, but you also know the price tag can be steep. If you have a dental plan through Preferred One, you are likely digging through your benefits booklet trying to figure out exactly what is covered.

Preferred One is a well-known insurance provider, particularly in the Midwest (especially Minnesota). They offer a variety of health and dental plans, often through employers. However, like most insurance companies, they do not offer a single “one-size-fits-all” answer when it comes to dental implants.

The short answer is: Preferred One may cover dental implants, but it depends entirely on the specific plan your employer purchased. Some Preferred One plans offer excellent implant benefits, while others may exclude them entirely or only pay a limited amount. This guide will help you understand how Preferred One dental plans work, how to check your specific benefits, and how to maximize your coverage for implants.

Understanding Preferred One Dental Networks

Before we dive into the specifics of implants, you need to understand how Preferred One structures its dental plans. They generally operate using a PPO (Preferred Provider Organization) model, and they often work in partnership with other dental networks to provide access to care.

The “Preferred One” Network
Historically, Preferred One has partnered with larger, national networks (like the Dental Benefit Providers network or similar) to provide access to dentists. This means your “Preferred One” card might actually be using a rented network.

Why does this matter for implants?
When you see a dentist who is “in-network,” you get the benefit of negotiated rates. The dentist has agreed to a contract with the network to charge a specific fee for a dental implant (code D6010). This contracted rate is almost always 20% to 40% lower than the “list price” you would pay if you walked in off the street.

If you are “out-of-network,” you may still have coverage, but you will be subject to “balance billing”—where the dentist charges their full fee, and Preferred One only reimburses based on their “allowed amount.”

The Standard Coverage Structure for Major Services

If your Preferred One plan covers dental implants, they will be classified as a “Major” or “Class III” service.

Here is how Preferred One (and most PPO plans) typically break down their coverage levels:

• Class I (Preventive): Cleanings, exams, X-rays. Often covered at 100%.
• Class II (Basic): Fillings, simple extractions, root canals. Often covered at 70-80%.
• Class III (Major): Crowns, bridges, dentures, and implants. Often covered at 50%.

The 50% Illusion
If your plan covers implants at 50%, you might think, “Great, I’ll pay half.” But it is rarely that simple due to the Annual Maximum Benefit.

The Annual Maximum
Preferred One dental plans have a cap on how much they will pay out per year. This is usually $1,000 to $2,000 per person.

Let’s do the math for a $4,500 implant:

1. 50% Coverage: $2,250.
2. Annual Maximum: $1,500.
3. Preferred One Pays: $1,500 (they hit the cap).
4. You Pay: $3,000.

As you can see, the annual maximum drastically limits the benefit for expensive procedures. The insurance company never pays more than the annual cap, no matter the percentage.

The “Alternate Benefit” Clause

This is a crucial concept for Preferred One members. Many plans that cover implants do so by using an “Alternate Benefit” rule.

How it works:

1. You need a single tooth replaced.
2. Preferred One’s standard policy is that a dental bridge is the “least expensive alternative treatment” (LEAT).
3. You insist on a dental implant, which is more expensive.
4. Preferred One will only pay 50% of what they would have paid for the bridge.

Example:

• Implant Cost: $4,500.
• Bridge Cost: $3,000.
• Preferred One would pay 50% of the Bridge: $1,500.
• Preferred One pays: $1,500 toward your implant.
• You Pay: $3,000.

While this is frustrating, it is still a benefit. You get the implant you want, and the insurance contributes the amount they would have spent on a cheaper alternative.

Step-by-Step: How to Check Your Preferred One Implant Coverage

Do not rely on guesswork. You must verify your specific plan. Here is the exact process to follow.

1. Log in to the Member Portal
Go to the Preferred One website (preferredone.com). Click on “Member Login.” If you haven’t registered, you will need your member ID from your insurance card.

2. Look for the “Evidence of Coverage” (EOC) or “Summary Plan Description” (SPD)
This is the legal document that outlines every detail of your plan. Download it. Use the “Ctrl+F” (search) function on your computer to search for the words:

• “Implant”
• “D6010” (the dental code for the implant post)
• “Major Services”

3. Check the Exclusions Section
Scroll to the “Exclusions” or “What is Not Covered” section. Look for phrases like:

• “Dental implants are not a covered benefit.”
• “Implant services are excluded.”
• “Alternate benefits apply.”

4. Call Customer Service
If the document is confusing, call the number on the back of your card. Ask the representative these exact questions:

• “Does my plan cover dental implants (Code D6010)?”
• “If so, at what percentage?”
• “Does the ‘alternate benefit’ rule apply to implants?”
• “What is my annual maximum, and how much of it is left for this year?”
• “Is there a ‘missing tooth clause’ in my plan?”

The “Missing Tooth Clause” Warning

Preferred One plans, like many dental plans, may have a “Missing Tooth Clause.”

This rule states that if a tooth was missing or extracted before you enrolled in the plan, the plan will not pay to replace it. The insurance company views it as a pre-existing condition.

Example: You lost a tooth in 2020. You got a new job with Preferred One insurance in 2023. The new plan will likely deny your claim for an implant because the tooth was already missing when you signed up.

However, if the tooth is extracted while you are enrolled in the plan, the replacement (the implant) is covered. This is a frustrating but standard industry practice.

Does Preferred One Cover the Crown Separately?

Remember that a dental implant is three parts: the post, the abutment, and the crown.

If your plan covers implants, it might cover the surgical placement of the post (D6010) under Major services. But the crown (D6058) might be processed as a separate claim.

In most cases, the crown is also covered at the 50% Major services rate. However, you must ensure the dentist submits claims for all three components. If they only submit the claim for the post, you will be left paying for the crown out-of-pocket.

What About the Medical Component?

If your implant requires complex preparatory surgery—like a major bone graft from your hip, or if it is being done in a hospital due to a medical condition—part of the procedure might fall under your Preferred One medical insurance rather than your dental insurance.

This is rare for standard single implants. But if you have a severe medical issue (like jaw cancer reconstruction), your medical plan might cover the hospitalization and anesthesia.

Strategies to Maximize Your Preferred One Benefits

If you find out your coverage is limited, don’t panic. You can use the system to your advantage.

1. The “Phased Treatment” Strategy
Implants take time. The process usually spans at least two calendar years.

• Year 1: Tooth extraction, bone graft, and implant post placement (Surgery).
• Year 2: Abutment placement and crown delivery (Restoration).

By splitting the work across two years, you can access two years’ worth of annual maximums. You might get $1,500 paid out in Year 1, and another $1,500 paid out in Year 2. This effectively doubles your insurance contribution.

2. The “Pre-Treatment Estimate”
Before you commit to the surgery, ask the dentist to submit a “Pre-Treatment Estimate” (also called a Predetermination) to Preferred One. The insurance company will review the plan and send you a written breakdown of exactly what they will pay, what the alternate benefit is, and what you owe.

This takes the guesswork out of the process. You will know your exact out-of-pocket cost before you sit in the chair.

3. Use Your FSA/HSA
You can use a Flexible Spending Account (FSA) or Health Savings Account (HSA) to pay for your portion of the implant cost. This uses pre-tax dollars, saving you 20-30%.

Conclusion

Preferred One may cover dental implants, but coverage is highly dependent on your specific plan. Most plans classify implants as a Major service (50% coverage), but the actual payout is limited by the annual maximum (usually $1,000-$2,000) and potentially by an “alternate benefit” rule (paying only the cost of a bridge). To know your exact cost, check your Evidence of Coverage, watch for missing tooth clauses, and request a pre-treatment estimate before starting treatment.

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Frequently Asked Questions (FAQ)

1. Does Preferred One cover “All-on-4” full mouth implants?
If your plan covers implants, it might contribute to the surgical placement of the individual implants. However, the fixed bridge (the denture part) is usually processed as a Major service. The annual maximum will be your biggest limitation. For a $25,000 procedure, a $1,500 annual maximum barely makes a dent.

2. Can I appeal if Preferred One denies my implant claim?
Yes. You have the right to appeal. You and your dentist will need to write a “Letter of Medical Necessity.” This should explain why an implant is medically superior to a bridge or denture (e.g., to prevent bone loss or to avoid damaging adjacent teeth). Include X-rays and clinical notes.

3. What if my dentist is out-of-network?
If you have a PPO plan, you can go out-of-network. However, Preferred One will reimburse based on their “allowed amount” (which may be low), and the dentist will bill you for the difference. Going in-network is almost always cheaper.

4. Does Preferred One have a waiting period for implants?
Many employer-sponsored plans have a waiting period for Class III (Major) services. This is often 6 or 12 months. If you just signed up for the plan, you may have to wait before they will pay for an implant.

5. Can I use my Preferred One medical card for dental implants?
Generally, no. Dental implants are a dental expense. However, if the surgery is being performed in a hospital setting due to a complex medical condition, or if it involves major jaw reconstruction, the medical plan might cover the hospital and anesthesia fees. This is a rare exception.