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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 plan.
| 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 |
| Dental Implants |
Initial placement to replace one or more natural teeth,
which are lost while covered by the Plan. |
| 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. |
- Dependents are eligible to age 21 (end of calendar year in
which they turn age 21). If a full time student, dependents are
eligible to age 24 (end of month in which they turn age 24).
- 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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