Dental Benefits

Payable at 80%

  1. Oral exams, prophylaxis (cleaning and polishing), and bitewing x-rays twice per calendar year (January 1 – December 31)
  2. Full mouth x-rays once in any consecutive 24-month period
  3. Emergency treatment
  4. Topical fluoride applications (to age 19)
  5. Endodontics, including pulpotomy, pulp capping and root canal therapy
  6. Denture repair and relining, and re-cementing of inlays, on-lays and crowns
  7. Extractions, dental tests, oral surgery and related anesthesia
  8. Fillings consisting of amalgam, silicate and plastic restorations, and sealants
  9. Space maintainers
  10. Periodontics (diseases of the gum) and apicoectomy

Payable at 50%

  1. Gold foil restorations, inlays and on-lays, and crowns and crown buildup
  2. Dentures, full and partial
  3. Bridges, fixed and removable
  4. Orthodontics (to age 19)
  5. Mandibular advancement and tongue restraining devices (for sleep apnea)

The date you take possession of a dental appliance will be the date the expense is incurred. The Plan will not pay for lost or misplaced dentures, cosmetic dentistry, implants or bridges involving dental implants; the placement of crowns, inlays and on-lays, bridges and dentures or the relining of dentures more than once per consecutive five-year period for the same tooth or teeth; general anesthesia for three or less simple extractions; hospital charges for out-patient surgery for the removal of impacted teeth, unless pre-approved by the Claim Administrator, or charges of a dentist except as set forth above.