Benefit Summary

Select A Plan That Meets Your Needs

Note: These rates are effective January 1, 2008 through December 31, 2008.
*Orthodontic services are only available to dependent children under the age of 19. Your child's orthodontic lifetime maximum balance will be carried over from your previous plan.

Preventive/Diagnostic Services
Plan pays 100%; Member Coinsurance 0%

• Two oral exams per calendar year
  
• Two cleanings per calendar year
  
• Fluoride treatment for children under age 19; twice per calendar year
  
• One bitewing series per calendar year
  
• Single x-rays as required
  
• Sealants for children under age 16, once per permanent molar in a 36 month period
  
• Space maintainers for lost deciduous (baby) teeth, replacement limited to once every 60 months

Basic/Minor Restorative Services
Plan pays 80%; Member Coinsurance 20% – Deductible Applies

• Procedures necessary to relieve acute pain, twice per calendar year
  
• Fillings: amalgam (silver) fillings; composite (white) fillings on front teeth (for composite fillings on back teeth, the plan pays what would have been paid for an amalgam filling)
  
• Extractions and other routine oral surgery when not covered by a patient's medical plan
  
• General anesthesia or intravenous (I.V.) sedation for complex surgical procedures
  
• Root canal therapy
  
• Repairs to existing partial or complete dentures once every 12 months
  
• Recementing crowns or bridges
  
• Rebasing or relining of partial or complete dentures; once every 60 months
  
• Periodontal maintenance following active therapy –- two per year
  
• Root planing and scaling once per quadrant every 24 months
  
• Osseous (bone) surgery once per quadrant every 24 months (bone grafts excluded)
  
• Gingivectomies and gingival curettage; once every 24 months
  
• Soft tissue grafts; once per site every 60 months
  
• Crown lengthening; once per site every 60 months

Major Restorative Services
Plan pays 50%; Member Coinsurance 50% – Deductible Applies

• Crowns over natural teeth, build ups, posts and cores; replacement limited to once every 60 months
  
• Bridges, build ups, posts and cores; replacement limited to once every 60 months
  
• Partial and complete dentures; replacement limited to once every 60 months

Orthodontics
Plan pays 50%; Member Coinsurance 50%

• Braces and related services for dependent children under the age of 19

Please note: Dependent children who are full-time students over age 19 are covered as long as they stay in school or up until the end of the month that they turn age 23.

To review exclusions & limitations click here.