|Calendar Year Deductible
- $75 per person; $225 per family
|Calendar Year Maximum
- In-Network: Plan pays up to $900 per person per calendar year toward all covered expenses.
- Out-of-Network: Plan pays up to $750 per person per calendar toward all covered expenses.
Note: The calendar year maximum does not apply to pediatric oral care.
|Preventive Care Services
- Oral exams and routine cleanings: twice in a calendar year
- Bitewing x-rays and fluoride applications for children under 19: once per calendar year
- Sealants for dependent children: once every three consecutive calendar years
- Full mouth x-rays: once every three consecutive calendar years
- Brush biopsy to detect oral cancer
- Emergency treatment to relieve pain
- Cleanings following periodontal therapy
|In- and Out-of-Network: Plan pays 100% of covered expenses, up to the reasonable and customary charge. There is no deductible.
|Non-Preventive Services (below are some examples; for a complete list refer to the Summary Plan Description posted to the Forms & Documents page)
- Space maintainers: once per lifetime
- Extractions and oral surgery services
- Fillings and crowns, repairs
- Root canal therapy
- Gold inlays
- Bridges, implants and dentures: once per tooth in any five-year period
- Periodontic services to treat gum disease
|In- and Out-of-Network: Plan pays 75% of covered expenses, after the deductible, up to the reasonable and customary charge.