| Diagnostic...............................................................100% (no deductible) |
Provides all necessary procedures to assist the dentist in evaluating the existing Conditions to determine the required dental treatment.
Examinatons: two per calendar year
Diagnostic x-rays: Bitewings, two per calendar year. Full mouth x-rays once in a thirty-six (36) month period.
|
|
| Preventative............................................................100% (no deductible) |
Provides for:
Prophylaxis (cleaning): Two per calendar year.
Topical Flouride: Once every (12) months (through December of the year age (19 is attained or to age twenty-three (23) if they are a full time student). Space Maintainers for primary teeth to preserve existing space.
Dental Sealants: For dependent children on posterior permanent teeth.
|
|
| Basic Services................................................................................85% |
Oral Surgery: including extractions, cutting procedures in the mouth, and treatment of fractures and dislocations of the jaw. General anesthetics and their administration by an oral surgeon.
Regular Restorative Dentistry: Restoration including synthetic & amalgam fillings. If a tooth colored filling is used to restore back (posterior) teeth, benefits are limited to the amount paid for a silver filling.
Emergency: Emergency treatment for relief of pain.
|
|
| Major Services..............................................................................50% |
Restorative Crowns & Onlays: The necessary procedures for provision of crowns, jackets or onlays when teeth cannot be restored with amalgam, composite resin or plastic materials due to extensive caries or fractures.
Dental Implants: The necessary procedures for implants including the crown, bridge or denture over the implant.
Prosthodontics: The necessary procedures for repair or construction of bridges, partial and complete dentures.
|
|
| Orthodontics.................................................................................50% |
| Available for unmarried dependent children (through December 31 of the year age nineteen (19) is attained or to age twenty-three (23) if they are a full time student). |
|
| Maximum Benefits: |
$1500 per person per plan year
$1750 Lifetime Maximum for Orthodontics per eligible person |