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Type A - Preventative
Prophylaxis (cleanings)
Oral Examinations
Topical Fluoride Applications
X-rays
Space Maintainers
Sealants
|
How Many/How Often
- Two per calendar year, separated by a
six-month period.
- Two exams per calendar year separated by a six-month period.
- One fluoride treatment per calendar year for dependant children up to
19th birthday.
- Full mouth x-rays: one set per calendar year for adults, two sets per
calendar year
for children, separated by a six-month period.
- Space maintainers for dependant children up to 19th birthday.
- One application of sealant material every 60 months for each
non-restored, non-decayed
1st and 2nd molar of a dependant child up to 19th birthday.
|
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Type B - Basic Restorative
Fillings
Simple Extractions
Crown, Denture, and Bridge Repair
Endodontics
General Anesthesia
Oral Surgery
|
How Many/How Often
- Root canal treatment limited to once per tooth per 24 months.
- When dentally necessary in connection with oral surgery, extractions or
other
covered dental services. |
Type C - Major Restorative
Bridges and Dentures
Crowns/Inlays/Onlays
Periodontics |
How Many/How Often
- Initial placement to replace one or
more natural teeth.
- Dentures and bridgework replacement: one every 5 years.
- Replacement of an existing temporary full denture if the temporary
denture cannot be
repaired and the permanent denture is installed within 12 months
after the temporary
was installed.
- Replacement: once every 5 years.
- Periodontal scaling and root planing once per quadrant, every 24
months.
- Periodontal surgery once per quandrant, every 36 months.
- Total number of periodontal maintenance treatments and prophylaxis
cannot exceed
four treatments in a calendar year. |
Type D - Orthodontics
- Dependent children are covered until the end of the month of
their 19th birthday.
- All dental procedures performed in connection with orthodontic
treatment are payable as Orthodontia.
- Payments are on a repetitive basis.
- Benefit for initial placement of the appliance will be made
representing 20% of the total benefit.
- Orthodontic benefits end at cancellation of coverage.
The service categories and plan limitations shown above
represent an overview of your Plan of Benefits. This list presents the
majority of services within each category, but is not a complete description of
the Plan. A summary plan description will be made available following
your plan's effective date, and will govern if any discrepancies exist between
this overview and the actual summary plan description. |
