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Annual Maximum Benefit (Per Individual) — $2,000. Does not apply to dental exams, bitewing X-rays, fluoride and prophylaxis/cleanings.

Annual Deductible (Per Individual) — $50, applies only to Basic Restorative (Type B) and Major Restorative (Type C) Services.




Preventive (Type A)
(0% coinsurance, No Deductible)
Preventive (Type A) Description Frequency
You Pay: 0% Coinsurance — No Deductible
Prophylaxis (cleanings) Teeth cleaning, scaling and polishing, periodontal maintenance visits
  • Twice per calendar year
  • Two additional cleanings per calendar year for members who are pregnant, diabetic, have a suppressed immune system or have a history of periodntal therapy
Oral Examinations All types
  • Twice per calendar year
Topical Fluoride For eligible dependents under age 19
  • Once per calendar year
Bitewing X-rays  
  • Once per calendar year
Sealants Limited to non-restored, non-decayed first and second molars
  • Once every 5 years

Basic Restorative (Type B)
(20% coinsurance, Deductible Applies)
Basic Restorative
(Type B)
Description Frequency
You Pay: 20% Coinsurance — After Deductible
Fillings (Minor Restoration) Fillings that use amalgam, synthetic porcelain and plastic material
  • Once every 2 years per tooth
Simple Extractions Routine removal (through use of forceps) of tooth structure, minor smoothing of socket bone, and closure
  • As required
Emergency Palliative Treatment Minor procedures to temporarily reduce or eliminate pain
  • As required
Space Maintainers Replaces prematurely lost teeth, except for accidental injuries. For eligible dependents under age 14
  • Once every 5 years
X-rays  
  • Full mouth X-rays: one every 5 years
  • Periapical X-rays: as required

Major Restorative (Type C)
(50% coinsurance, Deductible Applies)
Major Restorative
(Type C)
Description Frequency
You Pay: 50% Coinsurance — After Deductible
12-month waiting period required, waived with proof of prior 12-month dental coverage
Oral Surgery Includes surgical extractions
  • As required
Implants Including related bone grafts
  • Once every 7 years per tooth
Bridges and Dentures  
  • Initial placement to replace one or more natural teeth, which are lost while covered by the Plan
  • Dentures and bridgework replacement: once every 7 years
Crowns/Inlays/Onlays  
  • Replacement once every 7 years
Endodontics Root canal and pulpal therapy
  • Once every 2 years per tooth
General Anesthesia When dentally necessary in connection with oral surgery, extractions or other covered dental services
Periodontics Treatment of gum disease and bone supporting the teeth
  • Periodontal scaling and root planing once per quadrant, once every 2 years
  • Periodontal surgery once per quadrant, once every 3 years

The service categories and plan limitations shown above represent an overview of plan benefits. This table presents the majority of services within each category, but is not a complete description of the plan.

The percentage you pay is based on the Negotiated Fee, which refers to the fee participating dentists agreed to accept as payment in full for covered services, subject to copayments, deductibles, cost sharing and benefit maximums. Negotiated fees are subject to change.


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