| 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. | |
| 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 |
80% |
| Class III | |
Oral Surgery 12-month waiting
period for major services: |
50%* |