Dental Benefits

Deductible (Individual/Family)

$50/$150

Annual Maximum Per Person

$1,000

Diagnostic & Preventative Services Include:
Cleanings – once every 6 months
Oral Exams, Bitewing X-Rays, Full-Mouth or Panoramic X-Rays

Topical Fluoride – to age 19, once every 6 months
Space Maintainers – dependents under age 14
Sealants – one per tooth per lifetime for dependent children under
age 16

100%

Basic Services Include:
Emergency pain relief, Oral Surgery (extractions)
Fillings – Amalgam (silver) & Composite (white) on all teeth
Stainless steel crowns for dependents under age 12
Endodontics: Root canal treatments and root canal fillings.

Periodontics: Includes procedures for the treatment of the
diseases of the tissues supporting the teeth

90% covered

Major Services Include:
Special Restorative – When teeth cannot be restored with a filling
material listed in Restorative Dentistry, crowns are provided.
Prosthodontics: Includes bridges, partial and complete dentures,
repairs and adjustments of bridges and dentures.

60%
covered

Orthodontia Coverage ($1,000 annual maximum) (To age 19)

50%

Employee

$0

Employee + Spouse

$14.34

Employee + Child(ren)

$24.74

Family

$41.00