In addition to the limitations shown in the Summary of Benefits, the following general limitations apply:

• Oral Examinations – Covered as a separate benefit only if no other service was performed during the visit other than prophylaxis and X-rays. Limited to once every 6 months.
• Complete Series or Panorex Radiographs – Limited to one time per consecutive 36 months. Exception to this limit will be made for Panorex Radiographs if taken for diagnosis of third molars, cysts, or neoplasms.
• Bite-wing Radiographs – Limited to 1 series of films per calendar year.
• Extraoral Radiographs Limited to 2 films per calendar year.
• Dental Prophylaxis – Limited to once every 6 months.
• Diagnostic Casts – Limited to one time per consecutive 24 months.
• Fluoride Treatments – Limited to covered persons under the age of 16 years, and limited to once every 6 months. Treatment should be done in conjunction with dental prophylaxis.
• Sealants – Limited to covered persons under the age of 16 years, and once per first or second permanent molar every consecutive 36 months.
• Space Maintainers – Limited to covered persons under the age of 16 years, once per lifetime. Benefit includes all adjustment within 6 months of installation.
• Restorations – Multiple restorations on one surface will be treated as a single filling. Composite restorations limited to anterior teeth only.
• Pin Retention – Limited to 2 pins per tooth; not covered in addition to Cast Restoration.
• Inlays and Onlays – Limited to one time per 5 calendar years. Covered only when a filling cannot restore the tooth.
• Crowns – Limited to one time per tooth per 5 calendar years. Covered only when a filling cannot restore the tooth.
• Post and Cores – Covered only for teeth that have had root canal therapy.
• Sedative Fillings – Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.
• Scaling and Root Planing – Limited to 1 time per quadrant per consecutive 24 months.
• Periodontal Maintenance – Limited to 2 times per consecutive 12 months following active and adjunctive periodontal therapy within the prior 24 months, exclusive of gross debridement.
• Full Dentures – No additional allowances for overdentures or customized dentures.
• Partial Dentures – No additional allowances for precision or semi-precision attachments.
• Relining and Rebasing Dentures – Limited to relining or rebasing performed more than 6 months after the initial insertions. Limited to 1 time per calendar year.