$1,000 Benefit Maximum per Member per Calendar Year

Deductible

$50 per member; $100 per family

Preventive Services
are covered at 100% of the allowed charge. Deductible does not apply.

Routine oral evaluations, twice per Calendar Year
Bitewing x-rays, once per Calendar Year
Full mouth survey, once every three years
Panoramic film, once every three years
Prophylaxis, twice per Calendar Year
Topical fluoride application, twice per Calendar Year
Palliative (emergency) treatment of dental pain

Basic Restorative Services are covered at 80% of allowed charge, after deductible is met.

Sealants on unfilled, undecayed permanent molars and bicuspids for dependent children (limit two per tooth)
Space maintainers
Fillings (pin retention – limit 2)
Endodontics including:
     Pulpotomy
     Pulp capping
     Root canal therapy
     Apicoectomy
     Root amputation
     Hemisection
     Bleaching of endodontically treated anterior permanent teeth
Surgical periodontal evaluation, once for each course of treatment
Gingivectomy
Gingival curettage
Mucogingival surgery
Osseous surgery
Periodontal scaling and root planning
Simple extractions
Surgical extractions
Anesthesia services

Major Prosthetic Services are covered at 50% of allowed charge, after deductible is met.

Inlays, onlays and crowns (not part of a fixed partial denture), replacement of lost or defective inlays, onlays or crowns, once every five years
Dentures, complete and partial, replacement of lost or defective dentures, once every five years
Tissue conditioning, twice per treatment sequence for relining or for new or duplicate dentures
Relining of immediate dentures, once during the year after insertion
Repair of dentures
Surgical implant procedures, including prosthetic restoration
Fixed partial denture, replacement of lost or defective fixed partial denture, once every five years
Oral maxillofacial surgery including:
     Temporomandibular joint treatment
     Craniomandibular joint treatment
     Fracture and dislocation treatment
     Frenulectomy
     Cyst and abscess diagnosis
Occlusal guard for treatment of Bruxism, once every three years
Occlusal guard for treatment of temporomandibular or craniomandibular joint disorder, once every three years