Type A – Preventive and Diagnostic Services
The dental plan pays 100% of covered expenses for Type A (preventive and diagnostic) services, with no deductible required.

Covered expenses for preventive and diagnostic services include Reasonable and Customary Charges for:

• oral examinations (once every six months)
• cleaning and scaling of teeth (once every six months)
• bite-wing X-rays (one set every six months)
• full mouth X-rays (one set every 24 months)
• topical fluoride applications for Children under age 19 (once every six months)
• space maintainers
• emergency treatment.

Type B – Oral Surgery and Restorative Services
After the deductible has been satisfied, the plan pays 80% of covered expenses for Type B (oral surgery and restorative) services.

Covered expenses for oral surgery and restorative services include Reasonable and Customary Charges for:

• amalgam fillings (charges for precious metals such as gold and for castings are considered based on Reasonable and Customary Charges for amalgam fillings)
• treatment of gum disease (periodontics)
• endodontic treatment, including root canal services
• extractions (except in connection with orthodontic treatment)
• oral surgery
• general anesthesia when determined necessary under the plan’s dental provisions.

Type C – Prosthodontic Services
After the deductible has been satisfied, the plan pays 50% of covered expenses for Type C (prosthodontic) services.

Covered expenses for prosthodontic services include Reasonable and Customary Charges for:

• inlays, onlays, crowns, and gold fillings
• fixed bridgework installed for the first time to replace missing natural teeth, including inlays and crowns as abutments, but excluding periodontal splinting
• full or partial dentures installed for the first time to replace missing natural teeth and adjacent structures and any adjustments required during the six-month period following installation
• repair or recementing of crowns, inlays, onlays, dentures, or bridgework
• replacement or modifications of dentures or bridgework if required:
• to replace one or more teeth extracted after the existing denture or bridgework was installed
• to replace an existing appliance which is at least five years old and cannot be made serviceable
• to replace a temporary denture that cannot be made permanent and has been in place 12 months or less.

Type D – Orthodontic Services
No deductible applies to Type D covered expenses.
 
All covered Children through age 23 are eligible to receive benefits for orthodontic services. At age 24, all coverage under the plan ends, even if a course of orthodontic treatment is ongoing.

The plan payment for covered expenses (initial and monthly) is based on a schedule of allowances for non-network providers. This schedule is available from the Benefit Plans Office. A PDP network provider is paid based on the PDP fee schedule.

Covered expenses for orthodontic services include charges for:

• braces
• surgical extractions
• X-rays
• retention checking
• surgical reposition of the jaw, facial bones and/or teeth to correct malocclusion.