Refer to the "Covered Expenses" section, provided on the following page, for details.

Services Covered

Amount of Coverage*

Calendar Year Maximum

$1,500

Lifetime Orthodontic Maximum

$1,500

Lifetime Maximum

$20,000

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

$50 per member

Services Covered

Amount of Coverage*

TYPE A – Preventive and Diagnostic Services:

• Oral Examinations

Covered 100%, once every 6 months

• Prophylaxis (cleanings)

Covered 100%, once every 6 months

• Full Mouth X-rays

Covered 100%, once every 24 months

• Bite-wing X-rays

Covered 100%, one set every 6 months

• Fluoride

Covered 100% under age 19

• Space Maintainers

Covered 100%

TYPE B – Oral Surgery and Restorative Services:

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

Covered 100%, once every 6 months

• Sealants

Not covered

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

Covered 50% after deductible

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

Covered 50% for dependents up to age 24

*  Reasonable and Customary Charges apply for non-network providers. The PDP network fee schedule applies for PDP providers.