2014 Dental Plan

Limitations

  • A panoramic film with or without other films is considered equivalent to a full-mouth series for coverage purposes. Coverage for multiple radiographs on the same date of service will not exceed the coverage level for complete mouth series
  • Charges for replacement of filling restorations are only covered once in a 24-month period, unless the damage to that tooth was caused by accidental injury not related to the normal function of the tooth or teeth (includes crowns, inlays and onlays)
  • Endodontic (root canal treatment) on the same tooth is covered only once in a two-year period. Re-treatment of the same tooth is allowed when performed by a different dental office
  • If an existing bridge or denture cannot be made satisfactory, a replacement will be covered only once in five years, but not during the first year of Coverage C benefits
  • If your membership is terminated before an orthodontic treatment plan is completed, coverage will be provided only to the end of the month of termination
  • Benefits will not be paid for repair or replacement of an orthodontic appliance
  • After completion of your orthodontic treatment plan or reaching your orthodontic lifetime maximum, no further orthodontic benefits will be provided