Introduction |
Benefits are limited to necessary treatment which is generally considered appropriate by the dental profession. It is paid up to the amount shown on the Dental Fee Schedule (A07) or Dental Fee Schedule (B07). For a description of the A07 Benefit Package and the B07 Benefit Package, click here. |
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Annual Deductible |
None |
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Annual Benefit |
$2,000 per family member for the A07 benefit package.
$1,500 per family member for the B07 benefit package. |
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Most Common Dental Procedures |
100% up to the scheduled amount |
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Implants |
50% with a $1,000 lifetime maximum for the A07 benefit package.
Dental implants are not available under the B07 benefit package. |
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Orthodontics |
50% with a $1,500 lifetime maximum for the A07 benefit package.
50% with a $1,000 lifetime maximum for the B07 benefit package. Benefits available for children only. |
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Preauthorization |
Required for dental implants, hospitalization and general anesthesia for routine dental services |
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Frequency Limitations |
Procedures shown here are limited to once per period indicated.
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6 months
Routine examinations; prophylaxis (periodontal prophylaxis following active periodontal treatment but not more than three times in a twelve-month period and in lieu of regular prophylaxis); and fluoride. |
12 months
A maximum of four supplementary bitewing x-rays; root planning or subgingival curettage (but not both); denture relines and rebases (but not both); and limited adjustments to occlusion (eight teeth or less) |
24 months
Amalgam or composite restorations on the same surface of a tooth; stainless steel crowns; and root canal treatment. |
36 months
The application of fissure sealants to bicuspids and molars |
60 months
Complete full mouth (including bitewings) or panoramic x-rays; crowns, inlays (but only as a unit of a fixed bridge) and onlays; replacement of fixed bridgework (including Maryland bridges) unless replacement is required to replace one or more teeth extracted after the existing denture or bridgework was installed; and the replacement of an existing prosthetic but only if it is unserviceable and cannot be made serviceable. |
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