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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 |
| 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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