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Plan Information
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Coverage by Plan
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Base Plan
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Buy-up Plan
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Diagnostic and Preventive Services
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80%
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90%
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• Oral exams, twice per calendar year
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• Bitewing and periapical X-rays, as needed
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• Full-mouth X-rays, once every 36 consecutive months
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• Cleanings, twice per calendar year
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• Fluoride, once per year for dependents under 19
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• Sealants, once per tooth every five year for dependents under 19, limited to non-decayed first and second permanent molars
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• Emergency palliative treatment
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• Space maintainers, once in five years for dependents up to age 16
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Basic Services
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80%
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90%
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• Restorative services using synthetic porcelain, amalgam and plastic material, including composite (white) fillings
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• Periodontics
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• Endodontics: Root canal filling and pulpal therapy
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• Extractions: Simple and surgical
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• Denture relines and repairs
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Major Services
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50%
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50%
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• Prosthetics: Bridges and dentures; replacements will be covered once in five years but not during the first year of coverage
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• Crowns, jackets, labial veneers, inlays and onlays when required for restorative purposes, once every five years
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Calendar Year Benefit Maximum
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$1,000 per person
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$2,000 per person
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Calendar Year Deductible
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$25 per person / $75 family limit
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Orthodontic Services
(for eligible dependents up to age 19)
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50%
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Separate Lifetime Orthodontic Maximum
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$1,000 per eligible dependent up to age 19
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