Benefit Schedule

Maximum calendar year benefit is $1,500 per insured person, which can be increased to $2,000. See Monthly Premium page.

Care	Benefit	Beginning On effective date
Preventive	80% No deductible	1* day of certificate
Basic Repairs	80% No deductible	After six months
Major Repairs Oral Surgery, Bridges, Crowns and Caps, Endodontics, etc.	50% No deductible	After 18 months
Orthodontia*	50% No deductible	After 24 months

* - Orthodontia is limited to covered children on the policy to a maximum of $500 per year, $1000 lifetime.  Children must be 18 or under at the time the expense is incurred.

Effective Date

First day of the month following receipt of application and payment.

Eligibility

Persons age 18 and over, their spouse and unmarried dependent children under age 19 (or 23 if a full time student). Subject to your State requirements.

Reimbursement

Will be to you or the providing dentist if you so direct, based upon the above percentage of the Reasonable and Customary (R&C) fees. R&C fees are determined by the general level of fees being charged by other providers of dental care in the state and/or ZIP code where the services are received.

Partial List of Definitions and Exclusions

Please review actual policy language with your dentist to insure this plan provides the coverage you desire.

Preventive Services

Starting on the certificate effective date

• Routine Oral Examinations two per year, approximately once every six months
• Prophylaxis (cleanings) two per year, approximately once every six months
• Topical Fluoride Once per year if needed, to age 16
• Space Maintainers non-orthodontic only

Basic Repairs

Starting six months and one day after the certificate effective date

• Diagnostic X-rays
• Bitewing X-rays two per year, approximately once every six months
• Simple, Uncomplicated Extractions
• Pin Retention of fillings
• Fillings using amalgam, silicate, acrylic or synthetic porcelain and composite material
• Antibiotic injections administered for any of the above by a Dentist

Major Repairs

Starting 18 months and one day after the certificate effective date

• Oral Surgery, Endodontics, Periodontics, Crowns and Caps, Dentures, Bridgework, Recementing Bridgework, Study Models (one every three year period), Restorations (inlays/onlays) and general anesthesia used with above.

Orthodontia Services

Starting 24 months and one day after the certificate effective date and applies only to insured children under age 19 and is subject to an annual maximum benefit of $500 and a lifetime per child benefit of $1000.

• Surgical Therapy
• Appliance Therapy
• Functional/Myofunctional Therapy

Expenses Incurred

An Eligible Expense is considered incurred on the following dates: For full and partial dentures - the date the final impression is taken; for fixed bridges, crowns, inlays and onlays - the date the teeth are first prepared; for root canal therapy - on the date the pulp chamber is opened; for periodontal surgery - on the date surgery is performed; for all other services - the date the service is performed.

Alternate Benefit

IF: 1) We determine that a less expensive alternate procedure, service or Course of Treatment can be performed in place of the proposed treatment to correct a dental condition; and
2) the alternate treatment will produce a professionally satisfactory result; then the maximum we will allow will be the charge for the less expensive treatment.

Exclusions

• Implants
• Sealants
• Adult Orthodontia
• Cosmetic Procedures
• Oral Hygiene Instructions
• Services provided when the policy is not in effect or provided prior to completion of the above waiting periods
• Complete list of exclusions can be reviewed in the policy.