| Plan
Effective 7/1/06 |
High
Option Plan |
Low
Option Plan |
Calendar
Year Deductible
(does not apply to preventive care or orthodontia) |
Individual:
$50 (NA Preventive)
Family: $150 |
Individual:
$50
Family: $150 |
|
Calendar Year Maximum |
$1,500
(does not include orthodontia) |
$500
(does not include orthodontia) |
|
Orthodontia Lifetime Maximum |
$1,500 |
Not Covered |
|
Preventive Care: Type A (100% No Deductible) |
High Option Plan |
Low
Option Plan |
|
Oral Exam |
2 exams each cal year |
2 exams each cal year |
|
Prophylaxis |
2 exams per cal year (age 14 and over, including
periodontal) |
2 exams per cal year (age 14 and over, including
periodontal) |
| 1
every 6 consecutive months
(under age 14) |
1
every 6 consecutive months
(under age 14) |
|
Topical Fluoride |
2 each cal year, up to age 19 |
2 each cal year, up to age 19 |
|
Full Mouth Series (panoramic or X-ray series with
or without bitewings) |
1 every 36 months |
1 every 36 months |
|
Sealants |
1st and 2nd molars (1 reapplication)
children ages 5-15
in 36 months |
1st and 2nd molars (1 reapplication)
children ages 5-15
in 36 months |
|
Space Maintainers |
Fixed or removable, limited to initial appliance
only & to children under age 16 |
Fixed or removable, limited to initial appliance
only & to children under age 16 |
|
Basic (Restorative and Surgical Care): Type
B 80% after Deductible |
High
Option Plan |
Low
Option Plan |
|
Restorations (other than gold or porcelain) including
study models (Amalgam, silicate, acrylic or plastic,
composite) Temporary fillings will be considered
a separate procedure. Benefits will be provided
for both temporary and permanent fillings. |
Amalgam, silicate, acrylic or plastic, composite
Same |
Amalgam, silicate, acrylic or plastic, composite
Same |
|
Extractions, simple and surgical removal of impacted
teeth |
80% |
80% |
|
Anesthesia (local, analgesic and IV sedation) no
separate allowance if billed separately |
Payable as part of dental allowance for procedure |
Payable as part of dental allowance for procedure |
|
General Anesthesia (for surgical extractions and
oral surgery |
For dental surgery only |
For dental surgery only |
|
Pulp Cap, Pulpotomy, pulp vitality test |
80% |
80% |
|
Root Canal (endodontics, includes all charges including
x-rays, tests and follow-up) |
80% |
80% |
|
Periodontal Prophylaxis |
Covered under Type A (100% no deductible) &
Ages 14 & over |
Covered under Type A (100% no deductible) &
Ages 14 & over |
|
Periodontal Scaling, Root Planning |
2 treatments per quadrant per calendar year |
2 treatments per quadrant per calendar year |
|
Pin as part of a restoration |
80% |
80% |
|
Splinting |
Part of Periodontal Service |
Part of Periodontal Service |
|
Oral Surgery
|
If more than one periodontal surgery is performed
in the same quadrant, only the service with the
highest allowance will be covered. |
If more than one periodontal surgery is performed
in the same quadrant, only the service with the
highest allowance will be covered. |
|
Apicoectomy |
80% |
80% |
|
Occlusal Guards |
80% |
80% |
|
Major (Prosthetics): Type C 3/4 50% after Deductible |
High
Option Plan |
Low
Option Plan |
|
Bridge (Pontics and Abutments) |
Existing appliance must be 5 yrs old and/or is
not serviceable
Replacement is necessary because of an accident
occurring while covered |
Not Covered |
|
Dentures, full and partial |
Existing appliance must be 5 yrs old and/or is
not serviceable
Replacement is necessary because of an accident
occurring while covered |
Not Covered |
|
Recementing bridges, crown or inlays |
50% |
Not Covered |
|
Repairs to dentures, partials, and bridges |
After 6 months of initial installation, unless
due to an accident or service is provided by another
dentist |
Not Covered |
|
Denture and partial adjustment, denture reline |
Not Covered |
Not Covered |
|
Add teeth to a partial |
50% |
Not Covered |
|
Precision attachments for removable dentures |
50% |
Not Covered |
|
Temporary dentures, bridges, partials |
No separate allowance for temporary; included in
cost of permanent |
Not Covered |
|
Replacement partial, denture or bridgework |
Existing appliance must be 5 yrs old and/or is
not serviceable
Replacement is necessary because of an accident
occurring while covered |
Not Covered |
|
Porcelain Restorations
Gold Foil, Gold Inlays, Gold Onlays |
50% |
Not Covered |
|
Crowns, includes post and core
(not part of bridge)
- Stainless steel, when tooth cannot be restored
with filling
- Porcelain fused to gold
- Porcelain fused to non-precious metal
- Non-precious metal (full cast)
|
Includes post and core (not part of bridge)
Existing appliance must be 5 yrs old and/or is
not serviceable
Replacement is necessary because of an accident
occurring while covered |
Not Covered |
|
Crown Buildup |
50% |
Not Covered |
|
Repair crowns, onlays, inlays |
50% |
Not Covered |
| Replacement
of Crown |
Existing
appliance must be 5 years old and/or is not serviceable
Replacement is necessary because of an accident
occurring while covered |
Not Covered |
|
Bonding - not covered as separate procedure |
50% |
Not Covered |
|
Implants |
50% |
50% |
| Orthodontia: Type D |
50% No Deductible |
|
A treatment plan is required to calculate the monthly
benefit. The initial benefit will be based on 33%
of the total charge with the remaining amount prorated
for the proposed treatment period. Monthly receipts
are not required. |
|
Includes consultation, study molds, X-rays, treatment
plan, retention appliance, full banded orthodontia,
and fixed or removable appliance for tooth guidance |
50%
R&C |
Not Covered |
| $1,500
Lifetime |
| Benefits
will be calculated for treatment in progress- |