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Dental
What Is Covered
The plans pay for many of the preventive, basic and major services
you and your family receive. The following services are covered under
each of the three plans.
| Prophylaxis (cleanings) |
Two per calendar year. |
| Oral Examinations |
Two exams per calendar year. |
| Topical Fluoride Applications |
One fluoride treatment per calendar year for dependent
children up to 18th birthday. |
| X-rays |
Full mouth X-rays: one every 36 months.
Bitewing X-rays: two sets per calendar year. |
| Sealants |
One application of sealant material every 5 years
for each non-restored, non-decayed 1st and 2nd molar of a dependent
child up to 19th birthday. |
| Fillings |
When dentally necessary in connection with oral surgery,
extractions or other covered dental services.
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| Simple Extractions |
| Crown, Denture, and Bridge Repair |
| Oral Surgery |
| Endodontics |
| General Anesthesia |
| Periodontics |
| Space Maintainers |
| Bridges and Dentures |
Initial placement to replace one or more natural
teeth, which are lost while covered by the Plan.
Dentures and bridgework replacement: one every 5 years.
Replacement of an existing temporary full denture if the temporary
denture cannot be repaired and the permanent denture is installed
within 12 months after the temporary denture was installed. |
| Crowns/Inlays/Onlays |
Replacement: once every 5 years. |
- Dependent children are covered until the end of the month of
their 19th birthday or the end of the month of their 23rd birthday
if unmarried, full-time students.
- All dental procedures performed in connection with orthodontic
treatment are payable as Orthodontia.
- Payments are on a repetitive basis.
- Benefit for initial placement of the appliance will be made representing
20% of the total benefit.
- Orthodontic benefits end at cancellation of coverage.
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*The service categories and plan limitations shown above
represent an overview of your Plan of Benefits. This document presents
the majority of services within each category, but is not a complete
description of the Plan. A summary plan description will be made available
following your plan’s effective date, and will govern if any discrepancies
exist between this overview and the actual summary plan description.
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