Premier Dental Benefits

Maximums / Deductibles
Plan year maximums, per member:
First year benefit maximum $750
Second year benefit maximum $1,000
Third year benefit maximum $1,250
Plan year deductible, per member $50
Covered Services
Service Premier Network Benefit

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

Class 1

Examinations/x-rays
(routine exam & bitewing x-rays once every six months)
Prophylaxis
(cleanings once every six months)
Fissure sealants
Fluoride

80%
Class 2

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

 80%
Class 3

Oral Surgery
(surgical extractions & certain minor surgical procedures)
Endodontic
(pulp therapy and root canal filling)
Periodontics
(treatment of tissues supporting the teeth)

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%