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. |
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Annual Deductible |
None |
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Annual Benefit |
$2,000 per family member |
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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 |
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Orthodontics |
50%; with a $1,500 lifetime maximum |
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Preauthorization |
Strongly recommended for any course of treatment costing $500 or more.
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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