-
-
Individual Annual Deductible
$0
-
Family Annual Deductible
$0
-
Individual Maximum Benefit
$1,500
-
Family Maximum Benefit
$3,000
-
Network
Dentemax
-
-
-
Individual Annual Deductible
$0
-
Family Annual Deductible
$0
-
Individual Maximum Benefit
$1,500
-
Family Maximum Benefit
$3,000
-
Network
Dentemax
-
PREVENTIVE/DIAGNOSTIC SERVICES
| Oral examinations | 0% Coinsurance 1 per consecutive 6 month period |
| Cleanings Adult/Child | 0% Coinsurance 1 per consecutive 6 month period |
| Fluoride | 0% Coinsurance 1 per consecutive 6 month period |
| Sealants (permanent molars only) | 0% Coinsurance 1 treatment per tooth per consecutive 36 month period |
| Bitewing Xrays | 0% Coinsurance 1 set per consecutive 12 month period |
BASIC RESTORATIVE SERVICES (A waiting period of 6 months applies in connection with all Basic Restorative Services.)
| Full mouth series Xrays* | 20% Coinsurance |
| Restorative Amalgam or Composite | 20% Coinsurance |
| Routine Tooth Extraction | 20% Coinsurance |
*1 per consecutive 60 month period
MAJOR RESTORATIVE SERVICES (A waiting period of 12 months applies in connection with all Major Restorative Services.)
| Endodontics | 50% Coinsurance |
| Periodontics | 50% Coinsurance |
| Dentures | 50% Coinsurance |
| Crowns | 50% Coinsurance |
| Complex Extraction | 50% Coinsurance |
| Local Anesthesia | 50% Coinsurance |
| Onlays | 50% Coinsurance |
| Implants | 50% Coinsurance |
1. Procedures which are not necessary and which do not have uniform professional endorsement.
2. Procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not
legally required to pay.
3. Any procedure, service or supply provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings
on crowns or bridge units on molar teeth shall always be considered cosmetic.
4. Replacement of lost or stolen appliances or dentures.
5. Replacement of teeth beyond the normal complement of 32.
6. Prescription drugs.
7. Orthodontic treatment.
8. Charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory
agencies and infection control.
9. Charges for travel time, transportation costs or professional advice given on the phone.
10. Any charge for any treatment performed outside of the United States other than for emergency treatment.
11.
Oral hygiene, plaque control, tobacco, and diet instruction, broken
appointments, completion of claim forms, personal supplies
(water pick, toothbrush, floss holder, etc.), duplication of xâ€rays and exams required by a third party.
12. Any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility.
13. Services that are deemed to be medical services.
14. Services or appliances which restore or alter occlusion or vertical dimension.
15. Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.
16. Fixed and removable appliances for correction of harmful habits.
17. Diagnosis and treatment of temporomandibular joint (TMJ) disorders.
18. Any item or procedure not specifically covered under this Schedule of Benefits.
19. This plan does not cover any services performed by out of network providers.
•The waiting period is the amount of time you must be enrolled in the plan before you are eligible to receive plan benefits for the treatments subject to the waiting period. For example, you enrolled in coverage effective July 1, the plan will not cover any portion of the costs for a basic restorative service until January 1 of the next year. The plan will not cover any portion of the costs for a major restorative service until July 1 of the next year.
•The purpose of this list of exclusions is solely to provide additional clarity regarding treatments, procedures, products, services, or any other items which are not covered under this plan. Accordingly, no exclusion shall be interpreted by negative implication, or otherwise, as evidence of the existence of coverage under this plan.
