Dental Benefits

Calendar Year Deductible
(Applied to Basic and Major Services)

$50 Individual

3X Family

$50 Individual

3X Family

$50 Individual

3X Family

Annual Maximum
Applied to Preventive, Basic and Major Services

$1,000

$1,000

$1,000

Dependent Age Limit

26

26

26

Preventive Services
• Bitewing x-rays, one set per benefit period

• Full-mouth x-rays (pano), once in any 36
month period

• Oral examinations, twice in any benefit period

• Periapical x-rays, as required

• Periodontal Maintenance, twice in any benefit
period (subject to
your prophylaxis frequency limitation)

• Prophylaxis (cleanings), twice in any benefit
period

• Sealants for dependent children under age 16,
once in 5 years

• Space Maintainers for dependent children
under age 16, once in
5 years

• Topical fluoride treatments for dependent
children under age
16, once in any benefit period

100%

100%

100%

Basic Services
Emergency palliative treatment

• Endodontics

• Fillings

• Oral Surgery (excluding extractions)

• Simple Extractions

• Surgical Extractions

80%

80%

80%

Major Services
• Bridges, once in 7 years

• Crowns, Inlays, Onlays, once in 7 years

• Dentures, once in 7 years

• General Anesthesia

• Implants, as well as bone grafts, are a
covered benefit. Limited to once in 7 years.

• Non-Surgical Periodontics

• Surgical Periodontics

50%

50%

50%

Orthodontia

Not Covered

Not Covered

Not Covered

Employee Only

$13.54

$29.33

Employee + Family

$36.50

$79.08