Plan Information

Coverage by Plan

Base Plan

Buy-up Plan

Diagnostic and Preventive Services



• Oral exams, twice per calendar year

• Bitewing and periapical X-rays, as needed

• Full-mouth X-rays, once every 36 consecutive months

• Cleanings, twice per calendar year

• Fluoride, once per year for dependents under 19

• Sealants, once per tooth every five year for dependents under 19, limited to non-decayed first and second permanent molars

• Emergency palliative treatment

• Space maintainers, once in five years for dependents up to age 16

Basic Services



• Restorative services using synthetic porcelain, amalgam and plastic material, including composite (white) fillings

• Periodontics

• Endodontics: Root canal filling and pulpal therapy

• Extractions: Simple and surgical

• Denture relines and repairs

Major Services



• Prosthetics: Bridges and dentures; replacements will be covered once in five years but not during the first year of coverage

• Crowns, jackets, labial veneers, inlays and onlays when required for restorative purposes, once every five years

Calendar Year Benefit Maximum

$1,000 per person

$2,000 per person

Calendar Year Deductible

$25 per person / $75 family limit

Orthodontic Services
(for eligible dependents up to age 19)


Separate Lifetime Orthodontic Maximum

$1,000 per eligible dependent up to age 19

Note: Balance billing may result for services rendered by out-of-network providers.