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Dental - Summary of Benefits

Dental services are divided into three parts:  Part I - Preventative Dentistry, Part II - Restorative Dentistry, and Part III Major Dentistry.  Co-payment rates will vary depending which Part the service is categorized as, and which Plan you are enrolled.  Listed below is an overview of covered charges by Part.

Once you have determined whether a procedure is covered, you can review your co-payment and deductible to calculate your out-of-pocket expenses.  Annual maximums range between $500 to $2,000 per covered individual.

 

Part I - Preventative Dentistry
 Cleaning Two times per calendar year
 Exam Two times per calendar year
 2 Bitewings Two times per calendar year
 Flouride Treatment Once per calendar year
 Panoramic or full mouth X-ray Once every 24 months
 Sealants (unrestored teeth only no age limit) Once every 24 months
Space Maintainer No age limit

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Part II - Restorative Dentistry/Oral Surgery

 Fillings Once per calendar  year (reduced to  amalgam rate on posterior teeth)
 Periodontal scaling and root planing Once every 24 months per quadrant
 Periodontal maintenance Four times per year
 General anesthesia Not a covered expense
 Nitrous Oxide Only dependents age 12 or under
 Intravenous Sedation Only when treatment warrants
 Pill Sedation Not a covered expense
 Behavior management Not a covered expense

 

Part III - Major Dentistry/Prosthesis**
 Night Guard (for bruxism and/or TMJ) Replacement once every 5 years
 Bridge Replacement once every 5 years
 Crown Replacement once every 5 years
 Partial or full denture Replacement once every 5 years
 Implants Replacement once every 5 years
 Inlays/onlays Replacement once every 5 years

**Please note that all major dentistry is paid on the prep date but the patient must be eligible on the preparation date. All major work reduced to the gold or metallic rate on posterior teeth

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