Coverage Options:  

Option 1

Option 2

Annual Benefit Maximum
 

$1,000

$1,000

Coverage Options:  

Option 1

Option 2

Examples of Covered Services and Co-Insurance Levels:

 
Type 1 • Preventive
Diagnostic Services
- Oral exams (once every 6 months)
- Full mouth X-rays (once every 60 months)
- Bitewing X-rays (once every 6 months)
- Single tooth X-rays (as needed)
Preventive
- Cleanings (limited to 1 in a 6 month period)
- Periodontal cleanings (once every 3 months following
  active periodontal treatment, not to exceed 2 in a
  calendar year if combined with preventive cleanings)
- Fluoride treatments (limited to 1 in a 6 month period,
  under age 19)

 
100%

 
100%

 
Type 2 • Basic Restorative
Restorative
- Silver fillings (once every 24 months per surface per
  tooth)
- White fillings (once every 24 months per surface per
  tooth on front teeth; single surface only on back teeth)
- Temporary fillings (once per tooth)
Endodontics
- Root canal treatment
Oral Surgery*
- Simple extractions
- Surgical extractions
Periodontics*
- Periodontal surgery
- Scaling and root planing (once in 24 months, per
  quadrant)
* benefits not provided when rendered in a surgical day care or a hospital setting

 
80%

 
50%

 
Type 3 • Major Restorative
Prosthodontics
- Dentures (once within 60 months)
- Fixed bridges and crowns, when part of a bridge (once
  within 60 months)
Major Restorative
- Crowns, when teeth cannot be restored with regular
  fillings (once within 60 months per tooth)

 
50%

 
40%

 
Waiting Period: There is a six month waiting period on Type 2 services and a twelve month waiting period on Type 3 services.

 
Deductible: There is a $50 deductible per person up to $150 per family, on Type 2 and Type 3 Services.