This plan covers eligible expenses charged by a dentist. Benefits are subject to an annual deducible. The deductible is $50 per insured person per calendar year, to a maximum of $100 per family per calendar year.

Once the deductible has been met, the plan pays 80% for Basic Dental Care and 50% for Major Dental Care. Benefits are also limited to a maximum of $1,500 per insured person per calendar year.

Basic Dental Care

Diagnostic

• examinations (complete exam limited to once every 3 years)
  
• diagnostic x-rays (one full-mouth series or panorex every 3 years)
  
• bitewing x-rays (2 bitewings every 6 months)
  
• tests and cultures

Preventive

• preventive recall examinations (once every 9 months)
  
• fluoride (once every 6 months only for dependents under 16 years of age)
  
• pit and fissure sealants (only for dependents under 16 years of age)
  
• prophylaxis (once every 12 months per adult or every 6 months for dependents under 16 years of age)
  
• light scaling (8 units per year)
  
• space maintainers (for missing primary teeth)

Minor Restorative

• amalgam and composite restorations
  
• pins
  
• prefabricated full coverage restoration for primary teeth

Endodontic

• root canals and retreatment (one per tooth)
  
• apexification
  
• palliative dressings
  
• pulpotomy/pulpectomy
  
• endodontic surgery

Periodontic

• occlusal adjustment and/or equilibration (8 units per year)
  
• curettage and root planing
  
• gingivoplasty
  
• grafts
  
• guided tissue regeneration
  
• splinting

Oral Surgery

• simple and complicated extractions
• biopsies
  
• removal of cysts and tumors

Other

• anesthesia
  
• maintenance to existing dentures (every 24 months)

Major Dental Care

• initial installation, including adjustments of partial permanent or full temporary or permanent removable dentures, or the addition of teeth to an existing denture, to replace 1 or more natural teeth extracted while the person is insured;
  
• denture adjustments that occur more than 3 months after denture installation;
  
• replacement of an existing partial or full removable denture, if it - was installed at least 5 years before and cannot be made serviceable; or - is a temporary full denture which replaces 1 or more natural teeth extracted while the person is insured and for which replacement by a permanent denture is required and takes place within 1 year from the date the temporary denture was installed;
  
• addition of teeth to an existing partial denture, if required to replace 1 or more natural teeth extracted while the person is insured;
  
• inlays, onlays, gold fillings and crowns;
  
• initial installation of fixed bridgework, including crowns to form abutments, to replace 1 or more natural teeth extracted while the person is insured; and
  
• replacement of existing bridgework, but only if it was installed at least 5 years before and cannot be made serviceable.

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