Individual Dental Exchange Benefits

Maximums / Deductibles
Eligibility year* maximum, per member $1000
Eligibility year* deductible, per member $50
*The 12-month period beginning with the date you first become covered by the plan.
Covered Services
Service Benefit

*Covered services limited to $300 per member per eligibility year.

This is a benefit summary only. For a complete description of benefits, refer to your policy.

Class I - Preventive
Examinations/X-rays
(routine exam & bitewing x-rays once every six months)
Prophylaxis
(cleanings once every six months)
Fissure Sealants
Fluoride 		80%
Class II

Space Maintainers
Restorative Dentistry
(treatment of tooth decay with amalgam, synthetic porcelain and plastic materials)

80%
Class III

Oral Surgery
(surgical extractions & certain minor surgical procedures)

12-month waiting period for major services:
Crowns
Cast restorations
Dentures and bridge work
(construction or repair of fixed bridges, partials and complete dentures)

 50%*