Plan pays one
Annual Visit w/$10 co-pay. Pays for Oral Exams, including
Prophylaxis, Sealants up to age 13/
Topical Fluoride up to age 19.
Diagnostic Care - No
waiting Period
Diagnostic
Bitewing X-Rays, 1
per 12 months. Full mouth x-rays, plan pays 100% of
maximum covered expense, 1 per 36 months.
Deductible
Individual - $100 Lifetime
Family Limit - NONE
Basic - No Waiting Period
Basic Procedures
Simple Extractions Fillings, Repairs have no waiting
period. Plan pays according to schedule.
Major - 6 Month Waiting Period
Major Procedures
Periodontics, Endodontics, Oral Surgery, Crowns,
Dentures, Bridges, and Implants, have a 6 month waiting
period. Plan pays according to schedule.
Orthodontics - 12 Month Waiting Period
Orthodontics
Services
Covered at 50% with a 12 month waiting period, $500
annual maximum and $1,000 Life time maximum.
Orthodontic treatment for dependent children under age 19
