Dental

Type A Services - 1 month waiting period

Primary & Comprehensive
Routine Exams, once in 6 consecutive months
Prophylaxis– cleaning and scaling, once in 6 consecutive months
Bitewing/single x-rays– once in 6 consecutive months
Full mouth/ pancrex x-rays– once per 36 consecutive months
Fluoride treatment– for children up to age 18, once in 12 consecutive months
Sealant applications– for children up to age 13, once per 36 consecutive months
Space maintain-for children up to age 13, initial appliance
Emergency palliative treatment-immediate temporary relief when not included in other benefits
Type B Services - 1 month waiting period
Primary & Comprehensive
Restorative-amalgams, synthetic or plastic fillings
Periodontic services– treatment of the gums
Type C Services - 6 month waiting period
Comprehensive Only - Primary unavailable
Major restorative– inlays, onlays, crowns, post, and replacement of existing crown three years old +
Oral surgery-extractions surgically removed
Adjustment to bridges and dentures
Endodontic procedures– root canal therapy, pulp capping

Orthodontic Services - 6 month waiting period

Comprehensive Only - Primary unavailable
Braces and mechanical aids, children ages 6-18
Benefits and Premium
Primary Comprehensive
Type A Services 100% U/C* Subject to Deductible 100% U/C* Subject to Deductible
Type B Services 80% U/C* Subject to Deductible 80% U/C* Subject to Deductible
Type C Services Unavailable 50% U/C* Subject to Deductible
Orthodontic Services
Dependent Children
Age 6-18 Unavailable 50% U/C $500 calendar year per child
$1,000 lifetime maximum per
Calendar Year per Person (Maximum Benefit)

$750 all years
(Maximum Benefit)

$1,000 first year
$1200 second + years

Annual Deductible $50 per person
Family maximum of $150 annually $50 per person
Family maximum of $150 annually

* U/C = Usual and Customary