Annual Maximum Benefit (Per Individual) — $2,000. Does not apply to dental exams, bitewing X-rays, fluoride and prophylaxis/cleanings.
Annual Deductible (Per Individual) — $50, applies only to Basic Restorative (Type B) and Major Restorative (Type C) Services.
Jump to: Preventive | Basic Restorative | Major Restorative
Preventive (Type A) | Description | Frequency |
---|---|---|
You Pay: 0% Coinsurance — No Deductible | ||
Prophylaxis (cleanings) | Teeth cleaning, scaling and polishing, periodontal maintenance visits |
|
Oral Examinations | All types |
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Topical Fluoride | For eligible dependents under age 19 |
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Bitewing X-rays |
|
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Sealants | Limited to non-restored, non-decayed first and second molars |
|
Basic Restorative (Type B) |
Description | Frequency |
---|---|---|
You Pay: 20% Coinsurance — After Deductible | ||
Fillings (Minor Restoration) | Fillings that use (in 2020: posterior composite resin,) amalgam, synthetic porcelain and plastic material |
|
Simple Extractions | Routine removal (through use of forceps) of tooth structure, minor smoothing of socket bone, and closure |
|
Emergency Palliative Treatment | Minor procedures to temporarily reduce or eliminate pain |
|
Space Maintainers | Replaces prematurely lost teeth, except for accidental injuries. For eligible dependents under age 14 |
|
X-rays |
|
Major Restorative (Type C) |
Description | Frequency | You Pay: 50% Coinsurance — After Deductible |
---|---|---|---|
12-month waiting period required, waived with proof of prior 12-month dental coverage | |||
Oral Surgery | Includes surgical extractions |
|
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Implants | Including related bone grafts |
|
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Bridges and Dentures |
|
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Crowns/Inlays/Onlays |
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Endodontics | Root canal and pulpal therapy |
|
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General Anesthesia | When dentally necessary in connection with oral surgery, extractions or other covered dental services | ||
Periodontics | Treatment of gum disease and bone supporting the teeth |
|
The service categories and plan limitations shown above represent an overview of plan benefits. This table presents the majority of services within each category, but is not a complete description of the plan.
The percentage you pay is based on the Negotiated Fee, which refers to the fee participating dentists agreed to accept as payment in full for covered services, subject to copayments, deductibles, cost sharing and benefit maximums. Negotiated fees are subject to change.
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