Refer to the “Limitations” and “Exclusion” sections, on the following pages, for general limitations.

Services Covered

Amount of Coverage

Annual Deductible (applies to Basic and Major services)

$50 Individual
$100 Family

Annual Maximum Benefit

$1,000 per member

Services Covered*

Amount of Coverage**

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 3 years

• Bite-wing X-rays

Covered 100%, one set every 12 months

• Fluoride

Covered 100% under age 16, once every 6 months

• Sealants

Covered 100% under age 16, once per first or second permanent molar every consecutive 36 months

Basic Services:

• Space Maintainers

Covered 80% under age 16, once per lifetime

• Palliative Treatment (relief of pain)

Covered 80% after deductible
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

• General Anesthesia

Covered 80% after deductible when medically necessary

• Amalgam Restorations (fillings)

Covered 80% after deductible
Multiple restorations on one surface will be treated as a single filling

• Composite Restorations (fillings)

Covered 80% after deductible, for anterior teeth only
Multiple restorations on one surface will be treated as a single filling.

Major Services – 12-month waiting period applies

• Simple Extraction

Covered 50% after deductible

• Surgical Extraction including Impacted Wisdom Teeth

Covered 50% after deductible

• Root Canal Treatment

Covered 50% after deductible

• Scaling and Root Planing

Covered 50% after deductible, once per quadrant every 24 months

• Periodontal Surgery

Covered 50% after deductible, once every consecutive 36 months per surgical area

• Periodontal Maintenance

Covered 50% after deductible, twice per consecutive 12 months following active and adjunctive periodontal therapy within the prior 24 months, exclusive of gross debridement

• Crowns, Inlays and Onlays

Covered 50% after deductible, once every 5 years

• Fixed Bridges

Covered 50% after deductible, once every 5 years
Alternative benefits for a partial denture may be applied

• Full or Partial Dentures

Covered 50% after deductible, once every consecutive 60 months from initial or supplement placement

• Recement Bridges, Crowns and Inlays

Covered 50% after deductible, once every consecutive 60 months from initial or supplement placement

• Relining and Rebasing Dentures

Covered 50% after deductible, once per year for relining done more than 6 months after initial insertion

• Repairs to Full Dentures, Partial Dentures and Bridges

Covered 50% after deductible for repairs or adjustment performed more than 12 months after initial insertions