Dental Insurance for Fillings

Wisconsin Insurance Plans Cover Restorative Fillings

Fillings are one of the most common dental procedures performed in Wisconsin. The National Institute of Dental and Craniofacial Research estimates 92% of all adults have cavities and tooth decay. This decay can lead to cavities which require fillings to treat. Fortunately, Momentum Plans provides coverage for fillings through our dental insurance plans.

Cost of Fillings with and without Momentum Insurance Plans, Inc.:

2 Surface Fillings Cost without Insurance: $135

3 Surface Fillings Cost without Insurance: $160

4+ Surface Fullings Cost without Insurance: $170

Fillings Coverage with Momentum Gold & Platinum Insurance Plans: 60-75% Coverage

Learn more about our individual dental insurance plans, including rates, deductibles, coverage of dental services, and plan exclusions.

Filling Materials Covered by Momentum Plans

Fillings have been around for hundreds of years, though the materials used have evolved over time. Originally, pure mercury was used to fill the gaps created by cavities. Fortunately, filling materials have come a long way and are much safer to use.

Common fillings include:

• Gold
• Porcelain
• Amalgam
• Composite

Only amalgam and composite fillings are covered by Momentum Plans. Specifically, amalgam for posterior teeth and composites on anterior teeth. Amalgams are usually made from a silver alloy, though other materials are available as well. Like more expensive porcelain, plastic composite fillings are white to match the color of your teeth. Thanks to Momentum Plans insurance, they are available at a fraction of the cost.

Dental Fillings for All Ages, Families, & Occupations

Momentum has a variety of plans that cover different individuals, families, and job statuses.

• Kids
• Seniors over 65
• Veterans
• Small businesses
• Large businesses
• Part-time employees
• Federal employees

Aside from dental fillings, Momentum's insurance plans can also help with the cost of cleanings, other procedures, and more:

• Crowns
• Dentures
• Bridges

Customized Coverage for Restorative Dental Services

If you are looking for customized coverage, our individual and group plans are available. The individual Protect Plan has discounted fillings available through Dental Health Associates while certain group plans can include special coverage for fillings and other cavity treatments.

View Plan Deductibles, Coverage of Dental Services, and Annual Maximum Benefits OR Plan Exclusions.

Contact Momentum Plans to enroll for dental insurance coverage.

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Plan and Coverage Options

Step 1 of 5

SELECT YOUR PLAN (must choose an option)

Protect Plan:

Dental Health Associates Network

Gold Plan:

Dental Health Associates Network Commercial Network

Platinum Plan:

Dental Health Associates Network Commercial Network

Coverage Type

Single Couple Limited Family (1 adult + 1 child) Family Child/Children Only Number of children One Two Three Four

Select the number of Dependents One Two Three Four Five

Requested Effective Date

(must be the 1st of an upcoming month): //

Price Per Month:

(Plan and Coverage Type are Required for Pricing)

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Member Information

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First Name*

MI

Last Name*

* Male Female

Home Address*

City*

State*

Zip Code*

Primary Phone*

- -

Email*

Marital Status Married Single

*Date of Birth

/ /

How have you heard about us?

Please Select an Option Referral by Momentum Insurance Agent Referral by Existing Momentum Customer Web Search I am a Repeat Customer Outdoor Billboards Radio Print Ad (Magazine/Newspaper) Television Social Media (Facebook/Twitter/LinkedIn) Other

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Dependent Information

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No dependent info is needed if you choose single in plan coverage.

1. Dependent Info

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2. Dependent Info

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Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

3. Dependent Info

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Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

4. Dependent Info

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Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

5. Dependent Info

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Female

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Coordination of Benefits & Prior Coverage

Step 4 of 5

Just a Couple More Questions:

Are you, your spouse, or other dependents(s) covered by any other dental plan that will remain in effect

Yes No

Which Family members will be covered? Self Spouse Dependent(s)

Select the number of Dependents

One Two Three Four Five

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

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Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Has applicant had previous dental coverage?

Yes No

Which Family members had previous insurance? Self Spouse Dependent(s)

Select the number of Dependents One Two Three Four Five

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /

Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

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Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

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Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

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Complete Your Purchase of a Momentum Insurance Plan

Step 5 of 5

MONTHLY COST:

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3 Months

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Total Due Today:

Cardholder Name:*

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Expiration Date (MM/YY):*

Acceptance

I accept the Individual Plan coverage provided by Momentum Insurance Plans, Inc. I understand that by accepting insurance coverage, I am required to remit premiums according to the method of payment selected below on or before the 20th day of the month preceding the month of coverage for which payment is being made. Addition or deletion of dependents, and any other changes to coverage are allowed only based on a qualifying event as described in the Individual Plan policy. Coverage will be effective only upon acceptance and approval by Momentum Insurance Plans, Inc.

By signing this form, I certify that all information supplied is true to the best of my knowledge. I understand that all benefits for myself and my eligible dependents will be provided in accordance with the terms of the plan(s) in which I have enrolled and I agree to abide by the terms and conditions provided in the plan(s).

Please Sign The Electronic Signature Form Below

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By my signature above, I authorize Momentum Insurance Plans, Inc. to initiate a debit entry to the credit card account (Discover, MasterCard, Visa) indicated above in the amount of 3 months premium for the initial payment. Each month thereafter, debits will be made on the 20th day of the month, prior to the coverage month, for each monthly payment. This authority is to remain in full force and effective until Momentum Insurance Plans, Inc. and said financial institution have received written notification from me of its termination in such time and manner as to afford Momentum Insurance Plans, Inc. and said financial institution reasonable opportunity to act upon it. This card will be used for reoccurring payments unless we hear from you. Please contact us at 608.729.6500 to make other arrangements for reoccurring payments.

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