Covered Services

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.

Preventive (Type A)
(0% coinsurance, No Deductible)

Preventive (Type A)	Description	Frequency
You Pay: 0% Coinsurance — No Deductible
Prophylaxis (cleanings)	Teeth cleaning, scaling and polishing, periodontal maintenance visits	Twice per calendar year Two additional cleanings per calendar year for members who are pregnant, diabetic, have a suppressed immune system or have a history of periodontal therapy
Oral Examinations	All types	Twice per calendar year
Topical Fluoride	For eligible dependents under age 19	Once per calendar year
Bitewing X-rays		Once per calendar year
Sealants	Limited to non-restored, non-decayed first and second molars	Once every 5 years

Basic Restorative (Type B)
(20% coinsurance, Deductible Applies)

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	Once every 2 years per tooth
Simple Extractions	Routine removal (through use of forceps) of tooth structure, minor smoothing of socket bone, and closure	As required
Emergency Palliative Treatment	Minor procedures to temporarily reduce or eliminate pain	As required
Space Maintainers	Replaces prematurely lost teeth, except for accidental injuries. For eligible dependents under age 14	Once every 5 years
X-rays		Full mouth X-rays: one every 5 years Periapical X-rays: as required

Major Restorative (Type C)
(50% coinsurance, Deductible Applies)

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	As required
Implants	Including related bone grafts	Once every 10 years per tooth
Bridges and Dentures		Initial placement to replace one or more natural teeth, which are lost while covered by the Plan Dentures and bridgework replacement: once every 7 years
Crowns/Inlays/Onlays		Replacement once every 7 years
Endodontics	Root canal and pulpal therapy	Once every 2 years per tooth
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	Periodontal scaling and root planing once per quadrant, once every 2 years Periodontal surgery once per quadrant, once every 3 years

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.