Basic Plan Summary
The basic dental plan's maximum benefit per person on the plan is $1,000 per year, after the cost of annual cleanings and x-rays. The plan covers services based on the following details.
Service | Plan Pays | You Pay |
---|---|---|
Diagnostic and preventive | ||
Emergency palliative treatment | 100% | 0% |
Brush biopsy | 100% | 0% |
Radiographs (x-rays) | 100% | 0% |
Periodontal maintenance | 100% | 0% |
Minor and major restorative | ||
Endodontic | 65% | 35% (after $50 per year deductible) |
Periodontic | 65% | 35% (after $50 per year deductible) |
Oral surgery | 65% | 35% (after $50 per year deductible) |
Relines and repairs | 65% | 35% (after $50 per year deductible) |
Prosthodontic | 65% | 35% (after $50 per year deductible) |
Orthodontic age limit is age 24 for dependent children. Orthodontic lifetime limit per person is $1,000. |
50% | 50% |
Additional Details
- Oral exams (including evaluations by a specialist) are payable twice per calendar year.
- Prophylaxes (cleanings) are payable twice per calendar year.
- People with certain high-risk medical conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.
- Fluoride treatments are payable twice per calendar year with no age limit.
- Bitewing X-rays are payable once per calendar year and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.
- Composite resin (white) restorations are Covered Services on posterior teeth.
- Porcelain crowns are optional treatment on posterior teeth.
- Implants and implant related services are payable once per tooth in any five-year period.