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Routine Treatments

 
Basic Procedures
 		 100%
Routine Oral Surgery
 		 100%
Denture Relines, Rebases, Repairs
 		 100%

Initial Placement of Dentures
 

 100%
Calendar Year Maximun for both Basic and Major procedures combined
(*) prorated for new members see note below
 		 $2,500 per individual

Complete examination
 

 once every 24 months
Full mouth x-ray
 		 once every 24 months
recall or specific examination, including polishing and cleaning
 		 once every 6 months
Oral Hygiene Instruction
 		 once every 6 months
Denture Relines/Rebases/Repairs
 		 once every 36 months

 

CALENDAR YEAR MAXIMUM FOR BASIC AND MAJOR PROCEDURES WHEN MEMBER'S INSURANCE BECOMES EFFECTIVE ON:
January 1st to March 31st
 		 - $2,500 per individual
April 1st to June 31st
 		 - $1,500 per individual
July 1st to September 30th
 		 - $1,000 per individual
October 1st to December 31st
 		 - $ 500 per individual
For each year thereafter
 		 - $2,500 per individual

 
Covered Routine Services:

  • oral examinations including scaling, polishing and cleaning of teeth
  • topical application of sodium or stannous fluoride
  • dental x-rays: single diagnostic x-rays; complete series or equivalent
  • oral hygiene instruction
  • consultations
  • extractions
  • routine oral surgery including excision of impacted teeth
  • amalgam, acrylic, silicate or composite fillings, however molar teeth are limited to amalgam filling in accordance with the plan's policy to cover the least expensive suitable service.
  • retentive pins
  • anaesthesia where reasonably and customarily required in connection with other covered procedures
  • treatment of periodontal and other diseases of gums and tissues of the mouth, (special periodontal appliances)
  • emergency endodontic procedures and root canal therapy, limited to one course of treatment per tooth per lifetime
  • prefabricated full coverage restorations for primary teeth
  • passive space maintainers, those that do not move the teeth, and pit and fissure sealants for Dependent Children under the age of 18 only, for molar and bicuspid teeth
  • caries, trauma and pain control
  • study casts, once every twelve (12) months
  • repairing, relining and rebasing of dentures to the frequency of once every 36 months
  • initial installation of partial or full removable dentures to replace teeth lost, extracted or fractured after the effective date of this insurance
Forms & Brochures
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