Refer to the "Schedule of Benefits" section, provided on the following pages, for details.

Services Covered

            Amount of Coverage

Calendar Year Maximum

$1,500

Lifetime Orthodontic Maximum

$1,500

Lifetime Maximum

N/A

Annual Deductible (applies to Type B and Type C services only)

$50 per member

Services Covered

Amount of Coverage

TYPE A – Preventive and Diagnostic Services:

• Oral Examination

Covered 100%, twice every 12 months

• Prophylaxis (cleanings)

• Full Mouth X-rays

Covered 100%, once every 3 years

• Bite-wing X-rays

Covered 100%, two sets every 12 months

• Fluoride

Covered 100% under age 19

• Space Maintainers

Covered 100% under age 15

TYPE B – Basic Services:

• Fillings (other than gold), general anesthesia, occlusal guards, extractions and oral surgery, periodontics, endodontics (root canal therapy)

Covered 80% after deductible

• Sealants

Covered 80% under age 16, one benefit per tooth. Chewing surfaces for permanent first and second molars only.

TYPE C – Major Services (no age limit for bridges, partial dentures, or full dentures)

• Crowns

Covered 50% after deductible

• Bridges

Covered 50% after deductible, excluding porcelain, gold or veneer crowns for Children under age 12

• Partial Dentures/Full Dentures

Covered 50% after deductible, excluding fixed bridges or cast partials for Children under age 16

TYPE D – Orthodontic Services: braces, surgical repositioning to correct malocclusion, surgical extractions, X-rays, retention checking

Covered 50% for dependents up to age 24